Provider Demographics
NPI:1972070738
Name:RIESCHL, DEBORAH JEAN (CG60365859)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:RIESCHL
Suffix:
Gender:F
Credentials:CG60365859
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20110 VASHON HWY SW
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-6026
Mailing Address - Country:US
Mailing Address - Phone:206-463-5511
Mailing Address - Fax:206-463-5513
Practice Address - Street 1:20110 VASHON HWY SW
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-6026
Practice Address - Country:US
Practice Address - Phone:206-463-5511
Practice Address - Fax:206-463-5513
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60365859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60365859Medicaid