Provider Demographics
NPI:1831558238
Name:RIDENOUR, JEREMY MARK (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:MARK
Last Name:RIDENOUR
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 1:25 MAIN STREET
Mailing Address - Street 2:PO BOX 962
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01262-0962
Mailing Address - Country:US
Mailing Address - Phone:413-931-5283
Mailing Address - Fax:413-298-4020
Practice Address - Street 1:25 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01262-0962
Practice Address - Country:US
Practice Address - Phone:903-258-5876
Practice Address - Fax:413-298-4020
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0117056103T00000X
MA10216103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist