Provider Demographics
NPI:1114744273
Name:BIETZ, MICHA
Entity type:Individual
Prefix:
First Name:MICHA
Middle Name:
Last Name:BIETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9125 SOUTHERN RD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3609
Mailing Address - Country:US
Mailing Address - Phone:619-987-0134
Mailing Address - Fax:
Practice Address - Street 1:12396 WORLD TRADE DR STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3789
Practice Address - Country:US
Practice Address - Phone:858-768-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1235711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical