Provider Demographics
NPI:1508507856
Name:THACH, TINA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:THACH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:L
Other - Last Name:THACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:1831 S NEWKIRK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-1628
Mailing Address - Country:US
Mailing Address - Phone:267-752-9203
Mailing Address - Fax:
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:267-752-9203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN6355952084P0800X
PASP025735363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry