Provider Demographics
NPI:1255125027
Name:RIEDEL, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RIEDEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2314
Mailing Address - Country:US
Mailing Address - Phone:414-915-1194
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-1084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12274-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical