Healthcare Provider Details

I. General information

NPI: 1518960061
Provider Name (Legal Business Name): KENNETH L. RIDER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 02/03/2013
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

525 SOUTH DR SUITE 207
MOUNTAIN VIEW CA
94040-4213
US

IV. Provider business mailing address

525 SOUTH DR SUITE 207
MOUNTAIN VIEW CA
94040-4213
US

V. Phone/Fax

Practice location:
  • Phone: 650-988-0900
  • Fax: 650-948-1837
Mailing address:
  • Phone: 650-988-0900
  • Fax: 650-948-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY19767
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY19767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: