Provider Demographics
NPI:1902196306
Name:TIETKE, CORNELIA (LICSW)
Entity Type:Individual
Prefix:
First Name:CORNELIA
Middle Name:
Last Name:TIETKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5247 WISCONSIN AVE NW STE 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-2012
Mailing Address - Country:US
Mailing Address - Phone:202-271-5673
Mailing Address - Fax:
Practice Address - Street 1:5247 WISCONSIN AVE NW
Practice Address - Street 2:SUITE 2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2012
Practice Address - Country:US
Practice Address - Phone:202-271-5673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500790081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical