Provider Demographics
NPI:1386010676
Name:RIDLEY, CHARLES ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:RIDLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 UNIVERSITY DR E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3475
Mailing Address - Country:US
Mailing Address - Phone:812-340-1714
Mailing Address - Fax:
Practice Address - Street 1:3201 UNIVERSITY DR E
Practice Address - Street 2:SUITE 200
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3475
Practice Address - Country:US
Practice Address - Phone:812-340-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37060103T00000X
IN20041066A103T00000X
CAPSY9586103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist