Healthcare Provider Details

I. General information

NPI: 1205575263
Provider Name (Legal Business Name): ANNA RIDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE O
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

1421 LUISA ST STE O
SANTA FE NM
87505-4073
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-8618
  • Fax:
Mailing address:
  • Phone: 505-690-8618
  • 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: ANNA RIDER
Title or Position: LCSW
Credential: LCSW
Phone: 505-690-8618