Provider Demographics
NPI:1801252242
Name:RIEDEL, MARA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOUTH DAKOTA STATE UNIVERSITY
Mailing Address - Street 2:ADMIN (SAD) 100 BOX:2201
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57007
Mailing Address - Country:US
Mailing Address - Phone:605-270-1752
Mailing Address - Fax:
Practice Address - Street 1:800 NE 9TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-1104
Practice Address - Country:US
Practice Address - Phone:605-270-1752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD04482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer