Provider Demographics
NPI:1043450406
Name:BOUILLION, TINA HAN (MS, CADC II, LPC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:HAN
Last Name:BOUILLION
Suffix:
Gender:F
Credentials:MS, CADC II, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 SE 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5737
Mailing Address - Country:US
Mailing Address - Phone:971-291-0626
Mailing Address - Fax:458-224-0137
Practice Address - Street 1:333 NE RUSSELL ST STE 209
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3762
Practice Address - Country:US
Practice Address - Phone:971-291-0626
Practice Address - Fax:458-224-0137
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
ORC3283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500762021Medicaid