Healthcare Provider Details

I. General information

NPI: 1124542261
Provider Name (Legal Business Name): DESIREE MICHELLE TIET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 09/26/2023
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3576 ARLINGTON AVE STE 100
RIVERSIDE CA
92506-3907
US

IV. Provider business mailing address

3576 ARLINGTON AVE STE 100
RIVERSIDE CA
92506-3907
US

V. Phone/Fax

Practice location:
  • Phone: 951-374-1555
  • Fax: 951-394-7426
Mailing address:
  • Phone: 951-374-1555
  • Fax: 951-394-7426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number96242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: