Provider Demographics
NPI:1346419959
Name:COREY, TINA ANN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:ANN
Last Name:COREY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3109
Mailing Address - Country:US
Mailing Address - Phone:541-451-5932
Mailing Address - Fax:
Practice Address - Street 1:706 S I ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1622
Practice Address - Country:US
Practice Address - Phone:541-947-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
ORL53271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500698737Medicaid