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General NPI Number Information
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NPI Number | 1235367079
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Entity Type | Individual
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Provider Name | MR. CASEY RIDER
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Gender | Male
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Dates
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Enumeration Date | 07/01/2009
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Last Update Date | 01/03/2022
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Provider Practice Location Address
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Address Line | 280 W MACARTHUR BLVD
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City | OAKLAND
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State | CA
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Zip | 94611-5642
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Country | US
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Telephone | 510-752-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 36 ALTA VISTA WAY
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City | SAN RAFAEL
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State | CA
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Zip | 94901-3517
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Country | US
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Telephone | 415-465-5765
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 11221
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License Number State | CA
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