Basic Information
| Provider Information | |||||||||
| NPI: | 1124103981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE RIESTHAL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9488 NW 24TH RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523311786 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | NEUROLOGY SERVICE (127) | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA 6898 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.