Provider Demographics
NPI:1619145257
Name:BARRETT, TINA LANIER (MA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LANIER
Last Name:BARRETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARGARETE
Other - Last Name:LANIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9830 WYNGATE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4796
Mailing Address - Country:US
Mailing Address - Phone:919-400-8493
Mailing Address - Fax:
Practice Address - Street 1:2031 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-3342
Practice Address - Country:US
Practice Address - Phone:919-632-7641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1768103T00000X, 103TB0200X, 103TH0100X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service