MEDICARE: BETTY J RIDOUT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	4872	NY
2	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	298462	NY

General Provider Information

NPI Number	:	1124166566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY J RIDOUT

Provider Business Mailing Address
First Line	:	7 N ERIE ST
Second Line	:
City	:	MAYVILLE
State	:	NY
Zip	:	14757-1090
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 E 3RD ST
Second Line	:
City	:	JAMESTOWN
State	:	NY
Zip	:	14701-5433
Country	:	US
Telephone Number	:	716-661-8330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	09/11/2025

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