Provider Demographics
NPI:1194213918
Name:MATRIX BEHAVIORAL HEALTH PRACTICE LLC
Entity type:Organization
Organization Name:MATRIX BEHAVIORAL HEALTH PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEONA
Authorized Official - Last Name:RIDGEWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LSATP
Authorized Official - Phone:803-260-9897
Mailing Address - Street 1:12137 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-1352
Mailing Address - Country:US
Mailing Address - Phone:803-260-9897
Mailing Address - Fax:
Practice Address - Street 1:210 S BRADDOCK ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-4090
Practice Address - Country:US
Practice Address - Phone:703-853-0959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS525101YA0400X
103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty