Provider Demographics
NPI:1487327243
Name:RIESBECK, KELSEY (RD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:RIESBECK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CORTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-2157
Mailing Address - Country:US
Mailing Address - Phone:860-944-5590
Mailing Address - Fax:
Practice Address - Street 1:8 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3511
Practice Address - Country:US
Practice Address - Phone:203-916-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1717133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered