Provider Demographics
NPI:1922106715
Name:TIETBOHL, PHILLIP J (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:TIETBOHL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-2673
Mailing Address - Country:US
Mailing Address - Phone:610-413-1739
Mailing Address - Fax:
Practice Address - Street 1:232 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-2673
Practice Address - Country:US
Practice Address - Phone:610-741-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
PAPS008196L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001847159-0008Medicaid
PA001847159-0006Medicaid
PA001847159-0009Medicaid
PA001847159-0012Medicaid
PA001847159-0013Medicaid
PA001847159-0007Medicaid