Provider Demographics
NPI:1235681172
Name:RICHARDSON, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:RICHARDSON
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 1:1605 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-5137
Mailing Address - Country:US
Mailing Address - Phone:503-982-9300
Mailing Address - Fax:503-981-1302
Practice Address - Street 1:1605 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-5137
Practice Address - Country:US
Practice Address - Phone:503-982-9300
Practice Address - Fax:503-981-1302
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst