Provider Demographics
NPI:1477260719
Name:TIETZ, KRISTI LEE
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:LEE
Last Name:TIETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:LEE
Other - Last Name:PAWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 OKEMOS ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-1224
Mailing Address - Country:US
Mailing Address - Phone:175-833-8100
Mailing Address - Fax:
Practice Address - Street 1:42850 GARFIELD RD STE 103
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5026
Practice Address - Country:US
Practice Address - Phone:586-477-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)