Provider Demographics
NPI:1245298116
Name:RIDER-HILDRETH, LEANN M (LISW)
Entity type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:M
Last Name:RIDER-HILDRETH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GENESIS MENTAL HEALTH ASSOC
Mailing Address - Street 2:1218 CENTRAL AVE
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501
Mailing Address - Country:US
Mailing Address - Phone:515-571-4422
Mailing Address - Fax:515-576-6441
Practice Address - Street 1:GENESIS MENTAL HEALTH ASSOC
Practice Address - Street 2:1218 CENTRAL AVE
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501
Practice Address - Country:US
Practice Address - Phone:514-571-4422
Practice Address - Fax:515-576-6441
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA011551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0426189Medicaid
IA40679OtherBLUE CROSS BLUE SHIELD
IA40679Medicare ID - Type Unspecified