Provider Demographics
NPI:1437546868
Name:RIDER, STACY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1205 WORDSWORTH CT
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22802-4662
Mailing Address - Country:US
Mailing Address - Phone:607-765-6303
Mailing Address - Fax:
Practice Address - Street 1:1205 WORDSWORTH CT
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22802-4662
Practice Address - Country:US
Practice Address - Phone:607-765-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260018072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer