Provider Demographics
NPI:1982737722
Name:RIDER, RANDALL J (MS, LSW, LMFT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:RIDER
Suffix:
Gender:M
Credentials:MS, LSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 MAXIM DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6130
Mailing Address - Country:US
Mailing Address - Phone:260-312-0904
Mailing Address - Fax:
Practice Address - Street 1:4235 FLAGSTAFF COVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4418
Practice Address - Country:US
Practice Address - Phone:260-969-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000981A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist