Provider Demographics
NPI:1871258871
Name:CIEZKOWSKI, TINA M (LPCMH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:CIEZKOWSKI
Suffix:
Gender:F
Credentials:LPCMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3751 E PORTOLA VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7876
Mailing Address - Country:US
Mailing Address - Phone:516-376-1099
Mailing Address - Fax:
Practice Address - Street 1:3751 E PORTOLA VALLEY DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7876
Practice Address - Country:US
Practice Address - Phone:516-376-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TC1900X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty