Provider Demographics
NPI:1811354046
Name:RIDEAU, CESILEY (ATC)
Entity type:Individual
Prefix:
First Name:CESILEY
Middle Name:
Last Name:RIDEAU
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 N EL PASO AVE
Mailing Address - Street 2:HULL 128
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-8814
Mailing Address - Country:US
Mailing Address - Phone:479-968-0642
Mailing Address - Fax:479-498-6044
Practice Address - Street 1:1306 N EL PASO AVE
Practice Address - Street 2:HULL 128
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-8814
Practice Address - Country:US
Practice Address - Phone:479-968-0642
Practice Address - Fax:479-498-6044
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6982255A2300X
OK6942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer