Provider Demographics
NPI:1821743717
Name:RAIDER, AMBERLY NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:AMBERLY
Middle Name:NICOLE
Last Name:RAIDER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:AMBERLY
Other - Middle Name:NICOLEEEE
Other - Last Name:JARVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 W WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2472
Mailing Address - Country:US
Mailing Address - Phone:502-409-7181
Mailing Address - Fax:888-450-0935
Practice Address - Street 1:811 NORTHGATE BLVD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6419
Practice Address - Country:US
Practice Address - Phone:502-409-7181
Practice Address - Fax:888-450-0935
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-22-57891103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst