Provider Demographics
NPI:1295814713
Name:NIRK, TINA L (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:L
Last Name:NIRK
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:L
Other - Last Name:MANSFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:510 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2760
Mailing Address - Country:US
Mailing Address - Phone:844-895-7325
Mailing Address - Fax:
Practice Address - Street 1:1263 N 15TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2343
Practice Address - Country:US
Practice Address - Phone:307-745-8915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY744101Y00000X
WYLPC-744101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor