Provider Demographics
NPI:1003465196
Name:TIEDEMANN, ELIZABETH L (LGSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:TIEDEMANN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1236
Mailing Address - Country:US
Mailing Address - Phone:410-526-7882
Mailing Address - Fax:
Practice Address - Street 1:1560 CONROSE DR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-7200
Practice Address - Country:US
Practice Address - Phone:443-244-7892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25379104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker