Provider Demographics
NPI:1932356250
Name:RIDER, STEFANIE E (MA)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:E
Last Name:RIDER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16751 CLOVER RD # 1032
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-3646
Mailing Address - Country:US
Mailing Address - Phone:317-537-7483
Mailing Address - Fax:
Practice Address - Street 1:5927 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043
Practice Address - Country:US
Practice Address - Phone:317-537-7483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X
FLTPMC3198101YM0800X
NMCTB-2022-0724101YM0800X, 101YP2500X
COLPC.0019066101YP2500X
SCTLC435PC101YP2500X
VA701011944101YP2500X
IN39002259A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100264520Medicaid