Provider Demographics
NPI:1922149483
Name:TIETZ, CAROL (OTR L)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TIETZ
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-3833
Mailing Address - Country:US
Mailing Address - Phone:727-809-3326
Mailing Address - Fax:727-845-1811
Practice Address - Street 1:10521 HEARTH RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-3714
Practice Address - Country:US
Practice Address - Phone:352-683-7117
Practice Address - Fax:727-845-1811
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1010225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10656001OtherCITRUS HEALTHCARE NPR
FL880317000Medicaid
FL10656002OtherCITRUS HEALTHCARE SH