Provider Demographics
NPI:1780648022
Name:RIDER, RICHARD F (PSYD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:F
Last Name:RIDER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2241
Mailing Address - Country:US
Mailing Address - Phone:920-433-7992
Mailing Address - Fax:920-431-0333
Practice Address - Street 1:301 E SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2241
Practice Address - Country:US
Practice Address - Phone:920-433-7992
Practice Address - Fax:920-431-0333
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2677-057103T00000X
WI2677-57103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00776424Medicare Oscar/Certification
WI008770092Medicare Oscar/Certification