Provider Demographics
NPI:1174569487
Name:RIEDEL, ROBERT G (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:G
Last Name:RIEDEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7828
Mailing Address - Country:US
Mailing Address - Phone:320-491-1376
Mailing Address - Fax:
Practice Address - Street 1:7830 BELMONT DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-7828
Practice Address - Country:US
Practice Address - Phone:320-491-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0626103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN063L4RIOtherBLUE SHIELD OF MINNESOTA
MN531347300Medicaid
MN1042326OtherPREFERREDONE