Healthcare Provider Details

I. General information

NPI: 1982188397
Provider Name (Legal Business Name): STEPHANIE JANE RYDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W WOOD HILL DR STE 5
NAGS HEAD NC
27959-8700
US

IV. Provider business mailing address

PO BOX 1941
KILL DEVIL HILLS NC
27948-1941
US

V. Phone/Fax

Practice location:
  • Phone: 252-489-6373
  • Fax:
Mailing address:
  • Phone: 252-489-0026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPO12429
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC014620
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: