Healthcare Provider Details

I. General information

NPI: 1447700356
Provider Name (Legal Business Name): ALICIA TIEDRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 ELM AVE
LONG BEACH CA
90802-2426
US

IV. Provider business mailing address

456 ELM AVE
LONG BEACH CA
90802-2426
US

V. Phone/Fax

Practice location:
  • Phone: 562-437-6717
  • Fax: 562-437-5072
Mailing address:
  • Phone: 562-437-6717
  • Fax: 562-437-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number95441
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: