Provider Demographics
NPI:1306038526
Name:ROBERTS, TINA LYN (MA, LPC)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:LYN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-7113
Mailing Address - Country:US
Mailing Address - Phone:312-835-1634
Mailing Address - Fax:503-325-4986
Practice Address - Street 1:1 12TH ST STE 4
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4146
Practice Address - Country:US
Practice Address - Phone:312-835-1634
Practice Address - Fax:503-325-4986
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-11
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3758101YP2500X
WALH60691630101YP2500X
IL180006440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional