Healthcare Provider Details

I. General information

NPI: 1205166972
Provider Name (Legal Business Name): DALE RYDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2010
Last Update Date: 01/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 S PONDEROSA PARK RD
PRESCOTT AZ
86303-6146
US

IV. Provider business mailing address

4715 S PONDEROSA PARK RD
PRESCOTT AZ
86303-6146
US

V. Phone/Fax

Practice location:
  • Phone: 928-925-3191
  • Fax:
Mailing address:
  • Phone: 928-925-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW10344
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: