Provider Demographics
NPI:1134977754
Name:TIETEMA, MADELINE NICOLE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:NICOLE
Last Name:TIETEMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 RIVERLANDS CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9422
Mailing Address - Country:US
Mailing Address - Phone:616-216-8545
Mailing Address - Fax:
Practice Address - Street 1:551 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2355
Practice Address - Country:US
Practice Address - Phone:616-512-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician