Healthcare Provider Details

I. General information

NPI: 1619717246
Provider Name (Legal Business Name): KENNEDY GRACE RYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W THARPE ST STE 7
TALLAHASSEE FL
32303-5300
US

IV. Provider business mailing address

1000 W THARPE ST STE 7
TALLAHASSEE FL
32303-5300
US

V. Phone/Fax

Practice location:
  • Phone: 850-561-8060
  • Fax: 850-561-1143
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: