Provider Demographics
NPI:1104216597
Name:TIEU, RYAN KIM (ACSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KIM
Last Name:TIEU
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3323 W ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 29TH ST STE 201
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1119
Practice Address - Country:US
Practice Address - Phone:916-455-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAASW904261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health