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General NPI Number Information
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NPI Number | 1619865235
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Entity Type | Individual
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Provider Name | TINA CAROL FIETSAM LCSW, PPSC
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Gender | Female
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Dates
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Enumeration Date | 06/24/2025
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 1000 N ALAMEDA ST STE 390
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City | LOS ANGELES
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State | CA
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Zip | 90012-1804
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Country | US
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Telephone | 213-542-3838
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Fax |
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Provider Business Mailing Address
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Address Line | 21821 PALANCA
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City | MISSION VIEJO
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State | CA
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Zip | 92692-1010
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Country | US
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Telephone | 949-233-8119
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 19728
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License Number State | CA
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