Provider Demographics
NPI:1902001076
Name:TIETJEN, DWIGHT A JR (PT)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:A
Last Name:TIETJEN
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1807
Mailing Address - Country:US
Mailing Address - Phone:318-464-0553
Mailing Address - Fax:
Practice Address - Street 1:4801 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1807
Practice Address - Country:US
Practice Address - Phone:318-464-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist