Provider Demographics
NPI:1013095843
Name:RIEDL, GINA KIM (LPT)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:KIM
Last Name:RIEDL
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 MUIRFIELD CT
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-2403
Mailing Address - Country:US
Mailing Address - Phone:916-223-5778
Mailing Address - Fax:916-338-7535
Practice Address - Street 1:8725 WATT AVE
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-9747
Practice Address - Country:US
Practice Address - Phone:916-338-6449
Practice Address - Fax:916-338-7535
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340077AN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3464OtherCA DRUG MEDI-CAL#
CAPT 26123OtherLICENSED PSYCHIATRIC TECH