Provider Demographics
NPI:1851922488
Name:RYDSTROM, COURTNEY (MA, LPC, RPT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:RYDSTROM
Suffix:
Gender:F
Credentials:MA, LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 TUXEDO BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1840
Mailing Address - Country:US
Mailing Address - Phone:314-322-3229
Mailing Address - Fax:
Practice Address - Street 1:1001 BOARDWALK SPRINGS PL STE 113
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4777
Practice Address - Country:US
Practice Address - Phone:314-322-3229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017039214101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional