Provider Demographics
NPI:1629895578
Name:RIDLEY, TANDEKA NATASHA
Entity type:Individual
Prefix:
First Name:TANDEKA
Middle Name:NATASHA
Last Name:RIDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 SUSSEX DR APT 1417
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-5327
Mailing Address - Country:US
Mailing Address - Phone:954-559-1781
Mailing Address - Fax:
Practice Address - Street 1:1140 SUSSEX DR APT 1417
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-5327
Practice Address - Country:US
Practice Address - Phone:954-559-1781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-379379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty