Provider Demographics
NPI:1124206883
Name:PALMER, TINA RAE (BA PSRS)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:RAE
Last Name:PALMER
Suffix:
Gender:F
Credentials:BA PSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2212
Mailing Address - Country:US
Mailing Address - Phone:405-858-2733
Mailing Address - Fax:
Practice Address - Street 1:5 SW D AVE STE A
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4619
Practice Address - Country:US
Practice Address - Phone:580-250-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKN/AOtherN/A