Robert Myron Ridley, LPC – Professional Counselor

Key facts

NPI: 1891777264
Entity type: Individual (NPI type 1)
Primary specialty: Professional Counselor 101YP2500X
License: LPC0000001599 (TN)
Practice address: 441 E Broad St
Suite H
Cookeville, TN 38501-3389
Phone: (931) 544-1096
Fax: (931) 451-3774
NPI assigned: Nov 18, 2005
Sex: Male
Sole proprietor: Yes

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No

State licenses

License	State	Type	Specialty
LPC0000001599	TN	MD	Professional Counselor

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Professional Counselor	101YP2500X	LPC0000001599	TN	Yes

Addresses

Primary practice location

441 E Broad St
Suite H
Cookeville, TN 38501-3389

Mailing address

441 E Broad St
Suite H
Cookeville, TN 38501-3389
Phone (931) 544-1096

Other identifiers

Identifier	Type	State	Issuer
5441348	Medicaid	TN

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Dec 22, 2016.

{
    "created_epoch": "1132272000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1482364800000",
    "number": "1891777264",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "441 E BROAD ST",
            "address_2": "SUITE H",
            "city": "COOKEVILLE",
            "state": "TN",
            "postal_code": "385013389",
            "telephone_number": "931-544-1096",
            "fax_number": "931-451-3774"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "441 E BROAD ST",
            "address_2": "SUITE H",
            "city": "COOKEVILLE",
            "state": "TN",
            "postal_code": "385013389",
            "telephone_number": "931-544-1096",
            "fax_number": "931-451-3774"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RIDLEY",
        "first_name": "ROBERT",
        "middle_name": "MYRON",
        "name_prefix": "Mr.",
        "credential": "LPC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2005-11-18",
        "last_updated": "2016-12-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "TN",
            "license": "LPC0000001599",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5441348",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Cookeville, TN

All providers in Cookeville, TN · Professional Counselor in Tennessee

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 22, 2016. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.