Provider Demographics
NPI:1134529332
Name:RIECK, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:RIECK
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 1:3656 JACK PINE LN
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8021
Mailing Address - Country:US
Mailing Address - Phone:386-562-4623
Mailing Address - Fax:
Practice Address - Street 1:3656 JACK PINE LN
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8021
Practice Address - Country:US
Practice Address - Phone:386-562-4623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst