Provider Demographics
NPI:1205888054
Name:TIETJEN, CHRISTINA JO (PT)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:JO
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:JO
Other - Last Name:STRAUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:323 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-3200
Mailing Address - Country:US
Mailing Address - Phone:605-256-8915
Mailing Address - Fax:605-256-8983
Practice Address - Street 1:323 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3200
Practice Address - Country:US
Practice Address - Phone:605-256-8915
Practice Address - Fax:605-256-8983
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5835470Medicaid
SDS337220Medicare PIN