Provider Demographics
NPI:1346768405
Name:TIEDT, NICOLE (LPCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TIEDT
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41593 WINCHESTER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-4857
Mailing Address - Country:US
Mailing Address - Phone:951-254-7032
Mailing Address - Fax:
Practice Address - Street 1:41593 WINCHESTER RD STE 200
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4857
Practice Address - Country:US
Practice Address - Phone:951-254-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC8962101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPCC8962OtherBOARD OF BEHAVIORAL SCIENCES