Basic Information
| Provider Information | |||||||||
| NPI: | 1508188582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIEDEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1309 | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998331309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723332 | ||||||||
| FaxNumber: | 8888588850 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 NORTH NORDIC DRIVE | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077723332 | ||||||||
| FaxNumber: | 8888588850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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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 | 101YM0800X | 293 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MH1413 | 05 | AK | MEDICAID |