Provider Demographics
NPI:1265492524
Name:RYDER, DIANE T (LPA)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:T
Last Name:RYDER
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WILLOW LN
Mailing Address - Street 2:WEST PARK C61-2
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3551
Mailing Address - Country:US
Mailing Address - Phone:336-667-5151
Mailing Address - Fax:336-667-5048
Practice Address - Street 1:1430 WILLOW LN
Practice Address - Street 2:WEST PARK C61-2
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3551
Practice Address - Country:US
Practice Address - Phone:336-667-5151
Practice Address - Fax:336-667-5048
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135VNOtherBCBS OF NC
NC6107297Medicaid