Provider Demographics
NPI:1780090571
Name:DETIERRA, CAROLYN (MFT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:DETIERRA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 ALAMO LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-8908
Mailing Address - Country:US
Mailing Address - Phone:707-888-7519
Mailing Address - Fax:
Practice Address - Street 1:480 TESCONI CIR STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4691
Practice Address - Country:US
Practice Address - Phone:707-583-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist