Provider Demographics
NPI:1265769616
Name:CLIETT, THERESITA T
Entity type:Individual
Prefix:
First Name:THERESITA
Middle Name:T
Last Name:CLIETT
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 1:30 CHINKAPIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:BUNNLEVEL
Mailing Address - State:NC
Mailing Address - Zip Code:28323-9103
Mailing Address - Country:US
Mailing Address - Phone:910-893-3349
Mailing Address - Fax:
Practice Address - Street 1:351 WAGONER DR
Practice Address - Street 2:SUITE 150
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4608
Practice Address - Country:US
Practice Address - Phone:910-401-3855
Practice Address - Fax:910-202-2229
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health