Provider Demographics
NPI:1437228376
Name:ZIMMERMAN, TINA MARIE (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3891
Mailing Address - Country:US
Mailing Address - Phone:440-204-4315
Mailing Address - Fax:440-204-4315
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3891
Practice Address - Country:US
Practice Address - Phone:440-204-4315
Practice Address - Fax:440-204-4315
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0128721041C0700X
OHI19014301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S12024Medicare UPIN
PA066118FT5Medicare ID - Type Unspecified