Provider Demographics
NPI:1972337269
Name:TIETZ, LAUREN K (LMT, CST, TRE)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:K
Last Name:TIETZ
Suffix:
Gender:F
Credentials:LMT, CST, TRE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-0054
Mailing Address - Country:US
Mailing Address - Phone:512-699-1086
Mailing Address - Fax:
Practice Address - Street 1:1807 2ND ST # 45-3
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3499
Practice Address - Country:US
Practice Address - Phone:512-699-1086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT-2024-0073225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist