Provider Demographics
NPI:1083348346
Name:TIETJEN, ALLISON ROSE (OTD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:ROSE
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 CARIBOU CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5123
Mailing Address - Country:US
Mailing Address - Phone:402-560-7060
Mailing Address - Fax:
Practice Address - Street 1:200 COUNTRY BROOK DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2125
Practice Address - Country:US
Practice Address - Phone:817-562-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122838225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist