Provider Demographics
NPI:1891906509
Name:GRIDER, IDA JANE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:JANE
Last Name:GRIDER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4666 KELLYKRIS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-3411
Mailing Address - Country:US
Mailing Address - Phone:636-936-2466
Mailing Address - Fax:314-371-6508
Practice Address - Street 1:12755 OLIVE BLVD STE 115
Practice Address - Street 2:SUITE 115
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6242
Practice Address - Country:US
Practice Address - Phone:314-898-0100
Practice Address - Fax:314-371-6508
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101Y00000X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor