Provider Demographics
NPI:1396018990
Name:RIES, MICHELE (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:RIES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0002
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1221 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2849-57103G00000X, 103TC0700X
WI2849-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01315390Medicare PIN
WI61302OtherDEAN HEALTH INSURANCE
WI741501928Medicare PIN