Basic Information
| Provider Information | |||||||||
| NPI: | 1588221808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRIDEL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 997 SAINT SEBASTIAN WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309122613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067216597 | ||||||||
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| Practice Location | |||||||||
| Address1: | 997 SAINT SEBASTIAN WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309122613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067216719 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2019 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TH0004X | PSY004537 | GA | Y | Behavioral Health & Social Service Providers | Psychologist | Health |
No ID Information.