Provider Demographics
NPI:1629861406
Name:TETZLAFF, MARK R (LMSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:TETZLAFF
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3266 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-3760
Mailing Address - Country:US
Mailing Address - Phone:208-500-1875
Mailing Address - Fax:
Practice Address - Street 1:1110 W PARK PL STE 303
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2784
Practice Address - Country:US
Practice Address - Phone:208-261-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2071065104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker