Provider Demographics
NPI:1760524292
Name:TIETJEN, SUSAN JEANNE (LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEANNE
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-5038
Mailing Address - Country:US
Mailing Address - Phone:651-214-8088
Mailing Address - Fax:
Practice Address - Street 1:733 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-5038
Practice Address - Country:US
Practice Address - Phone:651-214-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist