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General NPI Number Information
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NPI Number | 1629861406
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Entity Type | Individual
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Provider Name | MARK R TETZLAFF LMSW
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Gender | Male
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Dates
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Enumeration Date | 05/26/2025
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Last Update Date | 05/28/2025
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Provider Practice Location Address
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Address Line | 1110 W PARK PL STE 303
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2784
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Country | US
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Telephone | 208-261-2255
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Fax |
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Provider Business Mailing Address
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Address Line | 3266 N 2ND ST
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City | COEUR D ALENE
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State | ID
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Zip | 83815-3760
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Country | US
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Telephone | 208-500-1875
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 2071065
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License Number State | ID
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