Basic Information
| Provider Information | |||||||||
| NPI: | 1174656623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIETJEN | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.M.F.T., R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 9TH ST | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955313432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074644349 | ||||||||
| FaxNumber: | 7074644572 | ||||||||
| Practice Location | |||||||||
| Address1: | 370 9TH ST | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955313432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074644349 | ||||||||
| FaxNumber: | 7074644572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 44340 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 163WP0808X | 376558 | CA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.