Provider Demographics
NPI:1215418868
Name:TIESLAU, RACHEL SULLIVAN (MA, MS, RDN, LD, LPC)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:SULLIVAN
Last Name:TIESLAU
Suffix:
Gender:F
Credentials:MA, MS, RDN, LD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 WILLIS RD SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2327 PANSY ST SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3804
Practice Address - Country:US
Practice Address - Phone:256-224-1665
Practice Address - Fax:833-629-8753
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2683133V00000X
ALLPC05283101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered