Provider Demographics
NPI:1508320938
Name:POVALERI, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:POVALERI
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 1:3841 N HOME AVE
Mailing Address - Street 2:
Mailing Address - City:DEPUTY
Mailing Address - State:IN
Mailing Address - Zip Code:47230-9080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3841 N HOME AVE
Practice Address - Street 2:
Practice Address - City:DEPUTY
Practice Address - State:IN
Practice Address - Zip Code:47230-9080
Practice Address - Country:US
Practice Address - Phone:812-599-2328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist