Provider Demographics
NPI:1225470081
Name:MILAN, TINA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:MILAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:TINA MARIE STANDIFER
Mailing Address - Street 1:PO BOX 1423
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-1423
Mailing Address - Country:US
Mailing Address - Phone:530-528-2342
Mailing Address - Fax:
Practice Address - Street 1:4300 FORT PECK ST
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9286
Practice Address - Country:US
Practice Address - Phone:530-338-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW35034101YM0800X
CA88858101YM0800X
CA002796971041C0700X
CALCSW88858101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty