Provider Demographics
NPI:1467672089
Name:RIDER, THOMAS W (MH 8601)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:RIDER
Suffix:
Gender:M
Credentials:MH 8601
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N ATLANTIC AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5045
Mailing Address - Country:US
Mailing Address - Phone:321-784-5367
Mailing Address - Fax:321-783-2290
Practice Address - Street 1:3000 N ATLANTIC AVE STE 102
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5045
Practice Address - Country:US
Practice Address - Phone:321-784-5367
Practice Address - Fax:321-783-2290
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health