Provider Demographics
NPI:1902016363
Name:DERTIEN, PAUL M
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:M
Last Name:DERTIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3769 CESAR CHAVEZ APT A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4316
Mailing Address - Country:US
Mailing Address - Phone:415-648-2661
Mailing Address - Fax:
Practice Address - Street 1:995 POTRERO AVE
Practice Address - Street 2:WARD 93
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2859
Practice Address - Country:US
Practice Address - Phone:415-206-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)