=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760603559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. SHERRY RIEDER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 CANNON ST SUITE A
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29403-5717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-259-0794
-----------------------------------------------------
Fax | 866-804-4951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 152 CANNON ST SUITE A
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29403-5717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-259-0794
-----------------------------------------------------
Fax | 866-804-4951
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 958
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------