Healthcare Provider Details

I. General information

NPI: 1255121315
Provider Name (Legal Business Name): KATIE RIEDESEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2025
Last Update Date: 05/10/2025
Certification Date: 05/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 SAINT NICHOLAS TER APT 34
NEW YORK NY
10027-2837
US

IV. Provider business mailing address

123 GROVE AVE STE 216
CEDARHURST NY
11516-2302
US

V. Phone/Fax

Practice location:
  • Phone: 913-634-6155
  • Fax:
Mailing address:
  • Phone: 516-350-8564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: