Provider Demographics
NPI:1518960061
Name:RIDER, KENNETH L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:RIDER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 SOUTH DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4213
Mailing Address - Country:US
Mailing Address - Phone:650-988-0900
Mailing Address - Fax:650-948-1837
Practice Address - Street 1:525 SOUTH DR
Practice Address - Street 2:SUITE 207
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4213
Practice Address - Country:US
Practice Address - Phone:650-988-0900
Practice Address - Fax:650-948-1837
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2013-02-03
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
CAPSY19767103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51043OtherNATIONAL REGISTER OF HEALTH CARE PSYCHOLOGISTS
CA109582OtherDIVISION OF WORKERS COMPENSATION-QME