Provider Demographics
NPI:1144422338
Name:BEVANS, TINA M (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:BEVANS
Suffix:
Gender:F
Credentials:LCSW
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 140353
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-0017
Mailing Address - Country:US
Mailing Address - Phone:918-313-2142
Mailing Address - Fax:
Practice Address - Street 1:3010 S HARVARD AVE
Practice Address - Street 2:STE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-6126
Practice Address - Country:US
Practice Address - Phone:918-313-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical