Provider Demographics
NPI:1619865235
Name:FIETSAM, TINA CAROL (LCSW, PPSC)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:CAROL
Last Name:FIETSAM
Suffix:
Gender:F
Credentials:LCSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21821 PALANCA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1010
Mailing Address - Country:US
Mailing Address - Phone:949-233-8119
Mailing Address - Fax:
Practice Address - Street 1:1000 N ALAMEDA ST STE 390
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1804
Practice Address - Country:US
Practice Address - Phone:213-542-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical