Provider Demographics
NPI:1114003092
Name:TIEFFENBACHER, THOMAS JAMES (MA,LP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JAMES
Last Name:TIEFFENBACHER
Suffix:
Gender:M
Credentials:MA,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MN
Mailing Address - Zip Code:56081-2158
Mailing Address - Country:US
Mailing Address - Phone:507-375-7405
Mailing Address - Fax:507-375-7405
Practice Address - Street 1:801 N. 2ND STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3373
Practice Address - Country:US
Practice Address - Phone:507-381-7829
Practice Address - Fax:507-375-7405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1176103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist