Provider Demographics
NPI:1962165340
Name:RISKE, ANTHONY NATHAN (MFTC)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:NATHAN
Last Name:RISKE
Suffix:
Gender:M
Credentials:MFTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 AGAPE WAY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-1487
Mailing Address - Country:US
Mailing Address - Phone:810-691-6689
Mailing Address - Fax:
Practice Address - Street 1:1359 AGAPE WAY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-1487
Practice Address - Country:US
Practice Address - Phone:810-691-6689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013863101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83-2340136OtherIRS