Provider Demographics
NPI:1124544523
Name:MCCLUSKEY, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MCCLUSKEY
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:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:WILLOW
Mailing Address - State:AK
Mailing Address - Zip Code:99688-0735
Mailing Address - Country:US
Mailing Address - Phone:907-354-3441
Mailing Address - Fax:
Practice Address - Street 1:19205 E FUTURE RD
Practice Address - Street 2:
Practice Address - City:TALKEETNA
Practice Address - State:AK
Practice Address - Zip Code:99676
Practice Address - Country:US
Practice Address - Phone:907-354-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities