Provider Demographics
NPI:1265612428
Name:TIETSORT, CHRISTOPHER KYLE (QUALIFIED PROFESSION)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:KYLE
Last Name:TIETSORT
Suffix:
Gender:M
Credentials:QUALIFIED PROFESSION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 550614
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0614
Mailing Address - Country:US
Mailing Address - Phone:704-301-2099
Mailing Address - Fax:704-866-4984
Practice Address - Street 1:543 COX RD
Practice Address - Street 2:SUITE D-4,5
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0607
Practice Address - Country:US
Practice Address - Phone:704-865-7818
Practice Address - Fax:704-866-4984
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health