Provider Demographics
NPI:1063994242
Name:RIEDESEL, DYLAN FANELLI (DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:FANELLI
Last Name:RIEDESEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 E GROUSE RD
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77905-0516
Mailing Address - Country:US
Mailing Address - Phone:361-550-8703
Mailing Address - Fax:
Practice Address - Street 1:225 E WARD ST
Practice Address - Street 2:
Practice Address - City:GOLIAD
Practice Address - State:TX
Practice Address - Zip Code:77963-4006
Practice Address - Country:US
Practice Address - Phone:361-645-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX127890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist