Provider Demographics
NPI:1538508403
Name:DUMONCEAUX, TINA KATHLEEN
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:KATHLEEN
Last Name:DUMONCEAUX
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 1:1824 SW TROY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2749
Mailing Address - Country:US
Mailing Address - Phone:541-905-5867
Mailing Address - Fax:
Practice Address - Street 1:420 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4603
Practice Address - Country:US
Practice Address - Phone:503-434-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health