Provider Demographics
NPI:1982227864
Name:RIDGEWAY, SANDRA KALYN (APC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KALYN
Last Name:RIDGEWAY
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:KALYN
Other - Middle Name:
Other - Last Name:RIDGEWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:29 PEBBLE WAY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2241
Mailing Address - Country:US
Mailing Address - Phone:706-980-3772
Mailing Address - Fax:
Practice Address - Street 1:37 CALUMET PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-6734
Practice Address - Country:US
Practice Address - Phone:770-304-0072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006956101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional