Provider Demographics
NPI:1861870818
Name:RIEGERT, JOANNE MARIE
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:MARIE
Last Name:RIEGERT
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 1:3035 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUBUN
Mailing Address - State:MN
Mailing Address - Zip Code:56589-9197
Mailing Address - Country:US
Mailing Address - Phone:218-473-2037
Mailing Address - Fax:
Practice Address - Street 1:1339 PELICAN LN
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2726
Practice Address - Country:US
Practice Address - Phone:218-847-8572
Practice Address - Fax:218-847-6113
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00978101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCC00978OtherSTATE OF MN, BOARD OF BEHAVIORAL HEALTH AND THERAPY