Provider Demographics
NPI:1568251056
Name:DE MEDEIROS CALIXTO, RIDAN SR
Entity type:Individual
Prefix:
First Name:RIDAN
Middle Name:
Last Name:DE MEDEIROS CALIXTO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 GRAY ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1774
Mailing Address - Country:US
Mailing Address - Phone:413-824-2946
Mailing Address - Fax:
Practice Address - Street 1:83 GRAY ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-1774
Practice Address - Country:US
Practice Address - Phone:413-475-4675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician