Healthcare Provider Details

I. General information

NPI: 1639019706
Provider Name (Legal Business Name): MELISSA ROSE RIEDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 N 28TH DR STE C202
PHOENIX AZ
85029-5600
US

IV. Provider business mailing address

16948 W NORTHAMPTON RD
SURPRISE AZ
85374-6893
US

V. Phone/Fax

Practice location:
  • Phone: 815-543-4384
  • Fax:
Mailing address:
  • Phone: 815-543-4384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-502779
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: