Provider Demographics
NPI:1023591690
Name:RIDGELL, EARL WESLEY JR (MA, MS, LCPC)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:WESLEY
Last Name:RIDGELL
Suffix:JR
Gender:M
Credentials:MA, MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4066 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-3601
Mailing Address - Country:US
Mailing Address - Phone:410-999-4886
Mailing Address - Fax:
Practice Address - Street 1:7800 WISE AVE STE 203
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-3338
Practice Address - Country:US
Practice Address - Phone:410-999-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP7740101Y00000X
MDLC9392101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD145280100Medicaid