Provider Demographics
NPI:1831519461
Name:RIDER, KELLY (ATC, CSCS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CHRISKEN DR
Mailing Address - Street 2:
Mailing Address - City:GLENMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12077-3249
Mailing Address - Country:US
Mailing Address - Phone:518-598-3973
Mailing Address - Fax:
Practice Address - Street 1:15 CHRISKEN DR
Practice Address - Street 2:
Practice Address - City:GLENMONT
Practice Address - State:NY
Practice Address - Zip Code:12077-3249
Practice Address - Country:US
Practice Address - Phone:518-598-3973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY67 0015672255A2300X
MA19582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer