Basic Information
| Provider Information | |||||||||
| NPI: | 1023677291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYDER | ||||||||
| FirstName: | ABIGAIL | ||||||||
| MiddleName: | MORIAH | ||||||||
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| Credential: | LSW, CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2685 ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303457949 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2685 ARMSTRONG RD | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446919041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303457949 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.170183 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | S.1904087 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0353401 | 05 | OH | MEDICAID |