Provider Demographics
NPI:1861412371
Name:JOHN B RIDGEWAY,LLC
Entity type:Organization
Organization Name:JOHN B RIDGEWAY,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BURNS
Authorized Official - Last Name:RIDGEWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LLP,LSW,CAC-1,SAP
Authorized Official - Phone:810-720-0640
Mailing Address - Street 1:G-4511 MILLER ROAD, 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-720-0640
Mailing Address - Fax:810-720-0640
Practice Address - Street 1:G-4511 MILLER ROAD, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507
Practice Address - Country:US
Practice Address - Phone:810-720-0640
Practice Address - Fax:810-720-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101948. CAC-1101YA0400X
MISAP101YA0400X
MI68010130861041C0700X
MI6301003780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P04330Medicare ID - Type UnspecifiedSOLE PROPRIETER
MIP2981001Medicare ID - Type UnspecifiedLLC