Provider Demographics
NPI:1073119632
Name:RYDER, KRISTEN (SSP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:RYDER
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12935 S WEST BAY SHORE DR STE 320
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5597
Mailing Address - Country:US
Mailing Address - Phone:231-268-0208
Mailing Address - Fax:
Practice Address - Street 1:12935 S WEST BAY SHORE DR STE 320
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5597
Practice Address - Country:US
Practice Address - Phone:231-268-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP0000000792258103TS0200X
MI68511179431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool