Provider Demographics
NPI:1093855512
Name:TIEMANN, GARY W (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:TIEMANN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 E 70TH STREET
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5393
Mailing Address - Country:US
Mailing Address - Phone:318-798-0518
Mailing Address - Fax:318-798-6697
Practice Address - Street 1:2001 E 70TH STREET
Practice Address - Street 2:SUITE 106
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5393
Practice Address - Country:US
Practice Address - Phone:318-798-0518
Practice Address - Fax:318-798-6697
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B658Medicare ID - Type Unspecified