Provider Demographics
NPI:1275204430
Name:TIETJEN, AMANDA S (MFT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:S
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BRADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4616
Mailing Address - Country:US
Mailing Address - Phone:386-258-1618
Mailing Address - Fax:
Practice Address - Street 1:430 BRADDOCK AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32118-4616
Practice Address - Country:US
Practice Address - Phone:386-258-1618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty