Provider Demographics
NPI:1528567187
Name:FOSTER, TINA LYN
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LYN
Last Name:FOSTER
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 1:2505 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2635
Mailing Address - Country:US
Mailing Address - Phone:574-289-4831
Mailing Address - Fax:
Practice Address - Street 1:51960 GUMWOOD RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-6207
Practice Address - Country:US
Practice Address - Phone:574-247-4665
Practice Address - Fax:574-247-4697
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst