Individual
ETHAN RIDENOUR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
COTA/L
Contact information
Practice address
320 4TH STREET, CARROLLTON, IL 62016-1135
(314) 328-9362
(618) 619-6881
Mailing address
320 4TH STREET, CARROLLTON, IL 62016-1135
(314) 328-9362
(618) 619-6881
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
057001592
IL
224Z00000X
Occupational Therapy Assistant
Primary
057004022
IL
225X00000X
Occupational Therapist
056004047
IL
235Z00000X
Speech-Language Pathologist
146010465
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1912319039
MEDICARE
IL
Enumeration date
05/22/2014
Last updated
10/15/2018
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