Healthcare Provider Details

I. General information

NPI: 1609111533
Provider Name (Legal Business Name): HEATHER MARIE TIETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 S. MAIN STREET
DELTA CO
81416
US

IV. Provider business mailing address

12575 2190 RD
ECKERT CO
81418-9404
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-9773
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: