Provider Demographics
NPI:1639750540
Name:NICOLE TIEDT, LICENSED PROFESSIONAL CLINICAL COUNSELOR, P.C.
Entity Type:Organization
Organization Name:NICOLE TIEDT, LICENSED PROFESSIONAL CLINICAL COUNSELOR, P.C.
Other - Org Name:THRIVING MINDS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIEDT
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:951-254-7032
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty