Provider Demographics
NPI:1386860757
Name:RIEDL, KELLIE (ATC CSCS)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:RIEDL
Suffix:
Gender:F
Credentials:ATC CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 THOMAS DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 MYERS FIELDHOUSE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6171
Practice Address - Country:US
Practice Address - Phone:507-381-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer