Provider Demographics
NPI:1215205190
Name:LAWSON, TINA DENISE (EDS)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:DENISE
Last Name:LAWSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S GILLETTE AVE
Mailing Address - Street 2:SUITE #203
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3740
Mailing Address - Country:US
Mailing Address - Phone:307-685-6982
Mailing Address - Fax:
Practice Address - Street 1:113 S GILLETTE AVE
Practice Address - Street 2:SUITE #203
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3740
Practice Address - Country:US
Practice Address - Phone:307-685-6982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1231101YP2500X
WYCERTIFICATION103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool