Provider Demographics
NPI:1891300539
Name:TIEDEMAN, MANDY (LMFT)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:LYNN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:119C GRISWOLD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1099
Mailing Address - Country:US
Mailing Address - Phone:860-918-7946
Mailing Address - Fax:860-735-5842
Practice Address - Street 1:119C GRISWOLD ST STE 202
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1099
Practice Address - Country:US
Practice Address - Phone:860-918-7946
Practice Address - Fax:860-735-5842
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2402106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist