Provider Demographics
NPI:1346310836
Name:VINCE, TINA ROSALIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ROSALIE
Last Name:VINCE
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 1:308 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-3027
Mailing Address - Country:US
Mailing Address - Phone:562-434-6383
Mailing Address - Fax:562-434-6383
Practice Address - Street 1:308 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-3027
Practice Address - Country:US
Practice Address - Phone:562-434-6383
Practice Address - Fax:562-434-6383
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30217106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist