Provider Demographics
NPI:1417922360
Name:RIEDER, KEITH LEE (EDD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LEE
Last Name:RIEDER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 MAPLE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2814
Mailing Address - Country:US
Mailing Address - Phone:304-599-5751
Mailing Address - Fax:304-599-2124
Practice Address - Street 1:1061 MAPLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2814
Practice Address - Country:US
Practice Address - Phone:304-599-5751
Practice Address - Fax:304-599-2124
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV580103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164008000Medicaid
WVY295240OtherMAGELLAN/HEALTH PLAN
WV047096OtherVALUE OPTIONS
WV0164008000Medicaid