Provider Demographics
NPI:1770043697
Name:RIESS, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:RIESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1706
Mailing Address - Country:US
Mailing Address - Phone:513-354-5200
Mailing Address - Fax:
Practice Address - Street 1:1501 MADISON RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILLS
Practice Address - State:OH
Practice Address - Zip Code:45206-1706
Practice Address - Country:US
Practice Address - Phone:513-354-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHC.2204643101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator