Provider Demographics
NPI:1497991806
Name:SHAH, TINA DINESH (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:DINESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4660 SLATER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4048
Mailing Address - Country:US
Mailing Address - Phone:612-276-2462
Mailing Address - Fax:612-246-3682
Practice Address - Street 1:12400 PORTLAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6817
Practice Address - Country:US
Practice Address - Phone:612-276-2462
Practice Address - Fax:612-246-3682
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680002766OtherMEDICARE PTAN