Provider Demographics
NPI:1093837452
Name:IVEY, TINA BAKER (CRC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:BAKER
Last Name:IVEY
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-4815
Mailing Address - Country:US
Mailing Address - Phone:478-275-0679
Mailing Address - Fax:478-275-0913
Practice Address - Street 1:420 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5222
Practice Address - Country:US
Practice Address - Phone:478-275-0679
Practice Address - Fax:478-275-0913
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator