MEDICARE: MR. STEVEN D TIETZE PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1121697	TX

General Provider Information

NPI Number	:	1386612174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEVEN D TIETZE PT

Provider Business Mailing Address
First Line	:	1500 WILDCAT DR STE H
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374
Country	:	US
Telephone Number	:	361-643-9900
Fax Number	:	361-643-9909

Provider Business Practice Location Address
First Line	:	1500 WILDCAT DR STE H
Second Line	:
City	:	PORTLAND
State	:	TX
Zip	:	78374
Country	:	US
Telephone Number	:	361-643-9900
Fax Number	:	361-643-9909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. STEVEN D TIETZE PT” Practice Location

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