Basic Information
| Provider Information | |||||||||
| NPI: | 1265492524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYDER | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 WILLOW LN | ||||||||
| Address2: | WEST PARK C61-2 | ||||||||
| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366675151 | ||||||||
| FaxNumber: | 3366675048 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 WILLOW LN | ||||||||
| Address2: | WEST PARK C61-2 | ||||||||
| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366675151 | ||||||||
| FaxNumber: | 3366675048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1958 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 135VN | 01 | NC | BCBS OF NC | OTHER | 6107297 | 05 | NC | MEDICAID |