Provider Demographics
NPI:1114042439
Name:RYDJORD, COLLEEN RAE (PSYCH TECH LICENSE)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:RAE
Last Name:RYDJORD
Suffix:
Gender:F
Credentials:PSYCH TECH LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WALNUT DRIVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003
Mailing Address - Country:US
Mailing Address - Phone:805-650-6712
Mailing Address - Fax:
Practice Address - Street 1:300 HILLMONT
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-652-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19592167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician