Provider Demographics
NPI:1881636264
Name:STRIDER, MARY ANN M (PHD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:M
Last Name:STRIDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 N 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2216
Mailing Address - Country:US
Mailing Address - Phone:402-333-5078
Mailing Address - Fax:
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE # 105
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-396-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00526103TC0700X
IA00157103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00526OtherMEDICAL LICENSE
IA0731968Medicaid
IA0731968Medicaid