Provider Demographics
NPI:1124542261
Name:TIET, DESIREE MICHELLE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MICHELLE
Last Name:TIET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3576 ARLINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3907
Mailing Address - Country:US
Mailing Address - Phone:951-374-1555
Mailing Address - Fax:951-394-7426
Practice Address - Street 1:3576 ARLINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3907
Practice Address - Country:US
Practice Address - Phone:951-374-1555
Practice Address - Fax:951-394-7426
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA962421041C0700X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner