Provider Demographics
NPI:1174068183
Name:RIDER, TRACY RAMONA (CMHC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:RAMONA
Last Name:RIDER
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7602 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1606
Mailing Address - Country:US
Mailing Address - Phone:315-771-4379
Mailing Address - Fax:315-785-9210
Practice Address - Street 1:7602 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1606
Practice Address - Country:US
Practice Address - Phone:315-771-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007933101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health