Provider Demographics
NPI:1306356530
Name:TIET, PHUONG GIA (BS)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:GIA
Last Name:TIET
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 ARNOLD DR STE 148
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-6538
Mailing Address - Country:US
Mailing Address - Phone:925-310-6311
Mailing Address - Fax:
Practice Address - Street 1:1330 ARNOLD DR STE 148
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-6538
Practice Address - Country:US
Practice Address - Phone:925-310-6311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-21-55466103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician