Provider Demographics
NPI:1730120932
Name:RIESE, AMY J (MS CCC - SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:RIESE
Suffix:
Gender:F
Credentials:MS CCC - SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7668
Mailing Address - Country:US
Mailing Address - Phone:920-456-7107
Mailing Address - Fax:
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-456-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1431-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42768900Medicaid