Provider Demographics
NPI:1225586522
Name:TIETJE, SHAKIRA TRIZETTE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHAKIRA
Middle Name:TRIZETTE
Last Name:TIETJE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 PRINCETON PL
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1118
Mailing Address - Country:US
Mailing Address - Phone:805-801-6003
Mailing Address - Fax:
Practice Address - Street 1:545 PRINCETON PL
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1118
Practice Address - Country:US
Practice Address - Phone:805-801-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15271225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist