Provider Demographics
NPI:1730546003
Name:TIEDEMAN, AMBER (PTA, CSCS)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:PTA, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S 21ST ST UNIT 130
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-3763
Mailing Address - Country:US
Mailing Address - Phone:719-634-1110
Mailing Address - Fax:
Practice Address - Street 1:600 S 21ST ST UNIT 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3763
Practice Address - Country:US
Practice Address - Phone:719-634-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1438225200000X
CO0013593225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant