Provider Demographics
NPI:1710510920
Name:TIEGEL, IVY (LMFT, MA, MFA)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:TIEGEL
Suffix:
Gender:F
Credentials:LMFT, MA, MFA
Other - Prefix:
Other - First Name:LISSAIVY
Other - Middle Name:
Other - Last Name:TIEGEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1254 MISSION ST STE 224
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2706
Mailing Address - Country:US
Mailing Address - Phone:415-787-5489
Mailing Address - Fax:
Practice Address - Street 1:1254 MISSION ST STE 224
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2706
Practice Address - Country:US
Practice Address - Phone:415-787-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-16
Last Update Date:2020-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist