Provider Demographics
NPI:1912442419
Name:TIEDE, RACHEL DAWN
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:DAWN
Last Name:TIEDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 FALCON RUN
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024-7515
Mailing Address - Country:US
Mailing Address - Phone:651-262-8144
Mailing Address - Fax:
Practice Address - Street 1:324 FALCON RUN
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:56024-7515
Practice Address - Country:US
Practice Address - Phone:651-262-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3397106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3397Medicaid