Provider Demographics
NPI:1255785473
Name:RIECKELMAN, ALYSSA (MA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:RIECKELMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:EMENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:331 LAGOON AVE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2316
Mailing Address - Country:US
Mailing Address - Phone:239-595-7753
Mailing Address - Fax:
Practice Address - Street 1:2345 STANFORD CT STE 602
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-4841
Practice Address - Country:US
Practice Address - Phone:398-802-0742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2023-01-11
Deactivation Date:2018-06-06
Deactivation Code:
Reactivation Date:2018-07-10
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
101YP2500X
FL21690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional