Basic Information
Provider Information | |||||||||
NPI: | 1831435791 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIDGLEY | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RIDGLEY-SMITH | ||||||||
OtherFirstName: | CHRISTINA | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LMHC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PH-INTENSIVE OUTPATIENT PROGRAM | ||||||||
Address2: | 2197-2251 O'CONNELL ROAD, BLDG 1056 | ||||||||
City: | FORT CARSON | ||||||||
State: | CO | ||||||||
PostalCode: | 80913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195267491 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 875 WAIMANU ST | ||||||||
Address2: | STE. 624 | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968135248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8087916713 | ||||||||
FaxNumber: | 8087916081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2012 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.