Provider Demographics
NPI:1649856147
Name:RIDGLEY, GALADREIL
Entity type:Individual
Prefix:
First Name:GALADREIL
Middle Name:
Last Name:RIDGLEY
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 1:3440 PARKMOOR VILLAGE DR APT V
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5269
Mailing Address - Country:US
Mailing Address - Phone:719-321-8412
Mailing Address - Fax:
Practice Address - Street 1:3440 PARKMOOR VILLAGE DR APT V
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5269
Practice Address - Country:US
Practice Address - Phone:719-321-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO263236050Medicaid