Provider Demographics
NPI:1528594009
Name:BELLEROSE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BELLEROSE
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 1:200 WILSON CIR
Mailing Address - Street 2:ST. JUDES RANCH FOR CHILDREN
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 WILSON CIR
Practice Address - Street 2:ST. JUDES RANCH FOR CHILDREN
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-4401
Practice Address - Country:US
Practice Address - Phone:603-381-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner