Provider Demographics
NPI:1588182760
Name:RIDER, DOREEN (LICSW)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 SAINT PAUL ST NW
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MN
Mailing Address - Zip Code:55965-1027
Mailing Address - Country:US
Mailing Address - Phone:507-216-1075
Mailing Address - Fax:
Practice Address - Street 1:401 16TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-7973
Practice Address - Country:US
Practice Address - Phone:507-473-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28831101YM0800X
NVIC-11401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health