Healthcare Provider Details

I. General information

NPI: 1245298116
Provider Name (Legal Business Name): LEANN M RIDER-HILDRETH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/11/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GENESIS MENTAL HEALTH ASSOC 1218 CENTRAL AVE
FORT DODGE IA
50501
US

IV. Provider business mailing address

GENESIS MENTAL HEALTH ASSOC 1218 CENTRAL AVE
FORT DODGE IA
50501
US

V. Phone/Fax

Practice location:
  • Phone: 514-571-4422
  • Fax: 515-576-6441
Mailing address:
  • Phone: 515-571-4422
  • Fax: 515-576-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01155
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0426189
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier40679
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: