Provider Demographics
NPI:1518275130
Name:WIBSTAD, TINA (LCSW, LSSW, CADC III)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:WIBSTAD
Suffix:
Gender:F
Credentials:LCSW, LSSW, CADC III
Other - Prefix:MS
Other - First Name:SINA
Other - Middle Name:
Other - Last Name:WIBSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LSSW, CADC III
Mailing Address - Street 1:906 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:906 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3816
Practice Address - Country:US
Practice Address - Phone:503-842-8201
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-06-70101YA0400X
OR105171921041S0200X
ORL59751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool