Provider Demographics
NPI:1942299532
Name:REIDER, MICHAEL ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:REIDER
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 1:9750 MIRAMAR ROAD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4562
Mailing Address - Country:US
Mailing Address - Phone:888-293-3182
Mailing Address - Fax:888-293-3182
Practice Address - Street 1:9750 MIRAMAR ROAD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4562
Practice Address - Country:US
Practice Address - Phone:888-293-3182
Practice Address - Fax:888-293-3182
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13784103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY137840OtherMEDI-CAL
CACP13784Medicare ID - Type UnspecifiedMEDICARE