Provider Demographics
NPI:1235431834
Name:RIESTERER, ALICIA MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:MARIE
Last Name:RIESTERER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 CAMPBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:VT
Mailing Address - Zip Code:05032-9069
Mailing Address - Country:US
Mailing Address - Phone:802-234-5274
Mailing Address - Fax:
Practice Address - Street 1:46 NICHOLS ST.
Practice Address - Street 2:RUTLAND HEALTHCARE AND REHABILITATION CENTER
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0730000138224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT224Z00000XMedicare PIN