Healthcare Provider Details

I. General information

NPI: 1063755684
Provider Name (Legal Business Name): MARY B. RIEDEL MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 5TH AVE S SUITE 301
LA CROSSE WI
54601-9200
US

IV. Provider business mailing address

317 GRANT ST
HOLMEN WI
54636-8614
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0827
  • Fax: 507-452-5183
Mailing address:
  • Phone: 608-399-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4671-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: