Provider Demographics
NPI:1568219806
Name:TIETZE, JOHANNA (CSW)
Entity type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:
Last Name:TIETZE
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 LOIS LN
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57032-2149
Mailing Address - Country:US
Mailing Address - Phone:605-900-6345
Mailing Address - Fax:
Practice Address - Street 1:815 LOIS LN
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:SD
Practice Address - Zip Code:57032-2149
Practice Address - Country:US
Practice Address - Phone:605-900-6345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
65101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical