Provider Demographics
NPI:1104296730
Name:RIDENOUR, RACHEL LAUREN (PT)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:LAUREN
Last Name:RIDENOUR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 6TH ST NW
Mailing Address - Street 2:APT 126
Mailing Address - City:OSSEO
Mailing Address - State:MN
Mailing Address - Zip Code:55369-1189
Mailing Address - Country:US
Mailing Address - Phone:405-880-0696
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-5486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1232721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist