Provider Demographics
NPI:1467664359
Name:TIESEL, JUDY (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:
Last Name:TIESEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 METRO BLVD
Mailing Address - Street 2:SUITE 413
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2316
Mailing Address - Country:US
Mailing Address - Phone:952-835-6950
Mailing Address - Fax:952-835-0072
Practice Address - Street 1:7400 METRO BLVD
Practice Address - Street 2:SUITE 413
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2316
Practice Address - Country:US
Practice Address - Phone:952-835-6950
Practice Address - Fax:952-835-0072
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3280103TF0000X
MN870106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8H911T1OtherBLUE CROSS-BLUESHIELD
MN6299691Medicaid