Provider Demographics
NPI:1730478066
Name:TIEDEMAN, MARK ANDREW (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:TIEDEMAN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
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Mailing Address - Street 1:5927 KANAN RD
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-1688
Mailing Address - Country:US
Mailing Address - Phone:818-889-0158
Mailing Address - Fax:818-889-4708
Practice Address - Street 1:5927 KANAN RD
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-1688
Practice Address - Country:US
Practice Address - Phone:818-889-0158
Practice Address - Fax:818-889-4708
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT27038225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist