Provider Demographics
NPI:1437779055
Name:HOUSTON, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HOUSTON
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 1:1210 HOLDEN DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3831
Mailing Address - Country:US
Mailing Address - Phone:706-750-4561
Mailing Address - Fax:
Practice Address - Street 1:1210 HOLDEN DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3831
Practice Address - Country:US
Practice Address - Phone:706-750-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011736225700000X
GAMY011736225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT011736Medicaid