Provider Demographics
NPI:1629350384
Name:NEWBERRY, TINA LAJEAN
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LAJEAN
Last Name:NEWBERRY
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 1:504 S WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-3642
Mailing Address - Country:US
Mailing Address - Phone:918-696-7190
Mailing Address - Fax:
Practice Address - Street 1:23 E ROSS AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6423
Practice Address - Country:US
Practice Address - Phone:918-216-4622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor