Provider Demographics
NPI:1023061074
Name:TIETJEN, LAURA ELIZABETH (MPT OCS)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:MPT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12917 W CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-5183
Mailing Address - Country:US
Mailing Address - Phone:253-228-6828
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE
Practice Address - Street 2:STE 146
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5674
Practice Address - Country:US
Practice Address - Phone:623-249-3216
Practice Address - Fax:623-249-3218
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00298975OtherRAILROAD MEDICARE PTAN
AZ107306Medicare ID - Type Unspecified