Provider Demographics
NPI:1891208815
Name:RIECK, KRISTIN LISA (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LISA
Last Name:RIECK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2367 STATE ST NE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-505-9161
Mailing Address - Fax:
Practice Address - Street 1:2367 STATE ST NE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4505
Practice Address - Country:US
Practice Address - Phone:503-505-9161
Practice Address - Fax:503-540-4097
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4635101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health