Provider Demographics
NPI:1417729310
Name:RYDER, ROBERT (LCPC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RYDER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 N PERRYVILLE RD UNIT 1100
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6827
Mailing Address - Country:US
Mailing Address - Phone:815-469-1500
Mailing Address - Fax:779-220-2189
Practice Address - Street 1:2990 N PERRYVILLE RD UNIT 1100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6827
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:779-220-2189
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180002981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health