Provider Demographics
NPI:1033692363
Name:RIESCHL, BRETT THOMAS
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:THOMAS
Last Name:RIESCHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 CORLANO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5231
Mailing Address - Country:US
Mailing Address - Phone:707-322-2573
Mailing Address - Fax:
Practice Address - Street 1:3550 ROUND BARN BLVD STE 112
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1796
Practice Address - Country:US
Practice Address - Phone:707-566-5269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist