Provider Demographics
NPI:1144598426
Name:PARKS, TINA MARIE
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:MARIE
Last Name:PARKS
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 1:1161 S LOOP RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-4765
Mailing Address - Country:US
Mailing Address - Phone:775-751-6990
Mailing Address - Fax:775-751-6992
Practice Address - Street 1:1161 S LOOP RD BLDG B
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-4765
Practice Address - Country:US
Practice Address - Phone:775-751-6990
Practice Address - Fax:775-751-6992
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01115I101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator