Provider Demographics
NPI:1851810964
Name:TIETJENS, LENAE JOY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LENAE
Middle Name:JOY
Last Name:TIETJENS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:LENAE
Other - Middle Name:J
Other - Last Name:TIETJENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:162 ASH ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 ASH ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1450
Practice Address - Country:US
Practice Address - Phone:708-497-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist