Basic Information
| Provider Information | |||||||||
| NPI: | 1376059089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDGEWAY | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2810 COLISEUM CENTRE DR # 502 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282173252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | 9807851114 | ||||||||
| Practice Location | |||||||||
| Address1: | 1138 2ND ST SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2017 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | VA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | VA | N |
No ID Information.