Healthcare Provider Details

I. General information

NPI: 1174728141
Provider Name (Legal Business Name): JULIE RYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 DIXWELL AVE
NEW HAVEN CT
06511-3456
US

IV. Provider business mailing address

29 GULL ROCK RD
MADISON CT
06443-3014
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: