Provider Demographics
NPI:1639828353
Name:LOVE, TIESIA R
Entity Type:Individual
Prefix:
First Name:TIESIA
Middle Name:R
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 E EL PASO AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2430
Mailing Address - Country:US
Mailing Address - Phone:559-521-5152
Mailing Address - Fax:
Practice Address - Street 1:4749 W SPRUCE AVE STE 107
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-3574
Practice Address - Country:US
Practice Address - Phone:559-521-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist