Provider Demographics
NPI:1700351905
Name:TISUE, MAMIE (LCSW)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:
Last Name:TISUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1355
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-1355
Mailing Address - Country:US
Mailing Address - Phone:309-236-3254
Mailing Address - Fax:
Practice Address - Street 1:134 F ST STE 209
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2160
Practice Address - Country:US
Practice Address - Phone:309-236-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099249681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical