Provider Demographics
NPI:1285023937
Name:RIEDL, KELLY (MS, BCBA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RIEDL
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BUDISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, DT
Mailing Address - Street 1:261 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128-1977
Mailing Address - Country:US
Mailing Address - Phone:262-370-6635
Mailing Address - Fax:
Practice Address - Street 1:2418 CROSSROADS DR STE 1600
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2420
Practice Address - Country:US
Practice Address - Phone:608-960-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI327-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst