=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215133806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT M RYDER MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 KELLOGG AVE FL 2
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92879-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-898-7173
-----------------------------------------------------
Fax | 951-898-7178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12159 NAVEL TREE CT
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92503-6775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-359-5135
-----------------------------------------------------
Fax | 951-359-5640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC24253
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------