Healthcare Provider Details

I. General information

NPI: 1417922360
Provider Name (Legal Business Name): KEITH LEE RIEDER ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 MAPLE DR SUITE 1
MORGANTOWN WV
26505-2814
US

IV. Provider business mailing address

1061 MAPLE DR SUITE 1
MORGANTOWN WV
26505-2814
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-5751
  • Fax: 304-599-2124
Mailing address:
  • Phone: 304-599-5751
  • Fax: 304-599-2124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number580
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: