Provider Demographics
NPI:1144743873
Name:TIESO, LUISA
Entity Type:Individual
Prefix:MRS
First Name:LUISA
Middle Name:
Last Name:TIESO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6167 SOMERS TER
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-3227
Mailing Address - Country:US
Mailing Address - Phone:862-432-0980
Mailing Address - Fax:
Practice Address - Street 1:6167 SOMERS TERR
Practice Address - Street 2:
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466
Practice Address - Country:US
Practice Address - Phone:862-432-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
PABH003283251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent