Provider Demographics
NPI:1073094546
Name:HERSTON, TINA K (DPT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:K
Last Name:HERSTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:VALENZUELA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-8008
Mailing Address - Fax:
Practice Address - Street 1:4138 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2403
Practice Address - Country:US
Practice Address - Phone:806-780-2329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL33871225100000X
FLPT33871225100000X
TX1349645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4285322Medicaid
TX8QC883OtherBCBS