Provider Demographics
NPI:1598960049
Name:PERRY, TINA DYANE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:DYANE
Last Name:PERRY
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:PO BOX 403516
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92340-3516
Mailing Address - Country:US
Mailing Address - Phone:760-241-4917
Mailing Address - Fax:760-241-8911
Practice Address - Street 1:13333 PALMDALE ROAD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2535
Practice Address - Country:US
Practice Address - Phone:760-241-4917
Practice Address - Fax:760-241-8911
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)