Provider Demographics
NPI:1073119632
Name:RYDER, KRISTEN (SSP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:RYDER
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:CEDAR
Mailing Address - State:MI
Mailing Address - Zip Code:49621-0240
Mailing Address - Country:US
Mailing Address - Phone:231-714-4485
Mailing Address - Fax:
Practice Address - Street 1:530 7TH AVE # M1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4878
Practice Address - Country:US
Practice Address - Phone:231-714-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP0000000792258103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool