Provider Demographics
NPI:1720582554
Name:TIEDGEN, JULIE (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:TIEDGEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2249 WEALTHY ST SE STE 120
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3052
Mailing Address - Country:US
Mailing Address - Phone:616-391-4650
Mailing Address - Fax:616-486-0134
Practice Address - Street 1:2249 WEALTHY ST SE STE 120
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3052
Practice Address - Country:US
Practice Address - Phone:616-391-4650
Practice Address - Fax:616-486-0134
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist