Provider Demographics
NPI:1538984422
Name:CAREY-TIEDTKE, ANNA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:CAREY-TIEDTKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 477 BOX 742
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96306-0008
Mailing Address - Country:US
Mailing Address - Phone:573-205-2512
Mailing Address - Fax:
Practice Address - Street 1:375 HEATHERLY LN
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MO
Practice Address - Zip Code:63068-2193
Practice Address - Country:US
Practice Address - Phone:573-205-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29597235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty