Healthcare Provider Details

I. General information

NPI: 1538826417
Provider Name (Legal Business Name): LAUREN ELIZABETH RYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18837 BROOKHURST ST STE # 110 & # 104
FOUNTAIN VALLEY CA
92708-7301
US

IV. Provider business mailing address

27261 LAS RAMBLAS STE 220
MISSION VIEJO CA
92691-6468
US

V. Phone/Fax

Practice location:
  • Phone: 877-527-7227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122603
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: