Provider Demographics
NPI:1629649306
Name:RIECK, TYLER LAWRENCE
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:LAWRENCE
Last Name:RIECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 FERNBROOK LN N STE 138
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4752
Mailing Address - Country:US
Mailing Address - Phone:952-544-0349
Mailing Address - Fax:
Practice Address - Street 1:2600 FERNBROOK LN N STE 138
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4752
Practice Address - Country:US
Practice Address - Phone:320-434-3028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician