Provider Demographics
NPI:1982497954
Name:RIDGELL, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:RIDGELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11197 RIENZI PL APT 102
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2751
Mailing Address - Country:US
Mailing Address - Phone:336-858-9389
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7182
Practice Address - Country:US
Practice Address - Phone:571-264-8192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health