Provider Demographics
NPI:1245419902
Name:TIETZE, RICHARD L (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:TIETZE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5425
Mailing Address - Country:US
Mailing Address - Phone:212-517-7123
Mailing Address - Fax:
Practice Address - Street 1:214 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5425
Practice Address - Country:US
Practice Address - Phone:212-517-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV46552Medicare PIN
NYV46551Medicare PIN