Provider Demographics
NPI:1265508675
Name:RIEDEL, ERICA LEE (MS, PT, CERT MDT)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:LEE
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:MS, PT, CERT MDT
Other - Prefix:MISS
Other - First Name:ERICA
Other - Middle Name:LEE
Other - Last Name:HANANEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PT, CERT MDT
Mailing Address - Street 1:44 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2519
Mailing Address - Country:US
Mailing Address - Phone:516-599-8734
Mailing Address - Fax:516-599-5969
Practice Address - Street 1:44 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2519
Practice Address - Country:US
Practice Address - Phone:516-599-8734
Practice Address - Fax:516-599-5969
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQB8691Medicare ID - Type UnspecifiedMEDICARE ID #