Provider Demographics
NPI:1912319039
Name:RIDENOUR, ETHAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:IL
Mailing Address - Zip Code:62016-1135
Mailing Address - Country:US
Mailing Address - Phone:314-328-9362
Mailing Address - Fax:618-619-6881
Practice Address - Street 1:320 4TH STREET
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016-1135
Practice Address - Country:US
Practice Address - Phone:314-328-9362
Practice Address - Fax:618-619-6881
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001592224Z00000X
IL056004047225X00000X
IL146010465235Z00000X
IL057004022224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1912319039OtherMEDICARE