Provider Demographics
NPI:1083628747
Name:KRIESBERG, RICKY (LMT)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:KRIESBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8862 NW 29TH PL
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5365
Mailing Address - Country:US
Mailing Address - Phone:954-341-7880
Mailing Address - Fax:954-575-0292
Practice Address - Street 1:8862 NW 29TH PL
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5365
Practice Address - Country:US
Practice Address - Phone:954-341-7880
Practice Address - Fax:954-575-0292
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35513225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist