Provider Demographics
NPI:1700494978
Name:RIEDL, MYKELA DANAE (DPT)
Entity Type:Individual
Prefix:
First Name:MYKELA
Middle Name:DANAE
Last Name:RIEDL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HOISINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67544-1811
Mailing Address - Country:US
Mailing Address - Phone:620-282-3673
Mailing Address - Fax:
Practice Address - Street 1:1514 K 96 HWY
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3012
Practice Address - Country:US
Practice Address - Phone:620-792-4383
Practice Address - Fax:620-792-2169
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-06498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist