Provider Demographics
NPI:1679349526
Name:TIESEL, ANGELA WOOLF
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:WOOLF
Last Name:TIESEL
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 1:7133 18TH AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3444
Mailing Address - Country:US
Mailing Address - Phone:561-706-1905
Mailing Address - Fax:
Practice Address - Street 1:11010 PRAIRIE LAKES DR STE 350
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3801
Practice Address - Country:US
Practice Address - Phone:952-746-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)