Provider Demographics
NPI:1063755684
Name:RIEDEL, MARY B (MS)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:B
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-8614
Mailing Address - Country:US
Mailing Address - Phone:608-399-1441
Mailing Address - Fax:
Practice Address - Street 1:115 5TH AVE S
Practice Address - Street 2:SUITE 301
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-9200
Practice Address - Country:US
Practice Address - Phone:608-785-0827
Practice Address - Fax:507-452-5183
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4671-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional