Provider Demographics
NPI:1205119401
Name:RIDENER, ANA DESIRAE (MOT)
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:DESIRAE
Last Name:RIDENER
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:503-570-3665
Mailing Address - Fax:
Practice Address - Street 1:1071 RENEE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2508
Practice Address - Country:US
Practice Address - Phone:208-233-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1081225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist