Provider Demographics
NPI:1407911332
Name:OUTLAW, TINA CELESTE (BSW,MSW, LISW-CP)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:CELESTE
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:BSW,MSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 JEFFORDS RD
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:SC
Mailing Address - Zip Code:29069-9494
Mailing Address - Country:US
Mailing Address - Phone:843-713-6205
Mailing Address - Fax:
Practice Address - Street 1:2919 JEFFORDS RD N
Practice Address - Street 2:OUTLAW'S VISION QUEST FARM, INC.
Practice Address - City:LAMAR
Practice Address - State:SC
Practice Address - Zip Code:29069-9494
Practice Address - Country:US
Practice Address - Phone:843-857-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1208Medicaid