Provider Demographics
NPI:1770181604
Name:BRUTSCHE, LIETTA DIANA (CADC II)
Entity Type:Individual
Prefix:
First Name:LIETTA
Middle Name:DIANA
Last Name:BRUTSCHE
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13682 YORBA ST
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1831
Mailing Address - Country:US
Mailing Address - Phone:714-730-5399
Mailing Address - Fax:
Practice Address - Street 1:13682 YORBA ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1831
Practice Address - Country:US
Practice Address - Phone:714-730-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA057610720101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)