Provider Demographics
NPI:1841742129
Name:ANGELL TIEDEMANN, MARY ELIZABETH (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:ANGELL TIEDEMANN
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
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Mailing Address - Street 1:10119 5TH PL SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-1931
Mailing Address - Country:US
Mailing Address - Phone:570-899-2278
Mailing Address - Fax:
Practice Address - Street 1:505 CEDAR AVE STE B1
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4561
Practice Address - Country:US
Practice Address - Phone:425-405-0837
Practice Address - Fax:425-382-2146
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01264L235Z00000X
WA61471998235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist