Provider Demographics
NPI:1669839254
Name:SUTHERLAND, TINA LYNN
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LYNN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:LYNN
Other - Last Name:KLOACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1045 EAST PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029
Mailing Address - Country:US
Mailing Address - Phone:619-201-2010
Mailing Address - Fax:
Practice Address - Street 1:1045 EAST PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029
Practice Address - Country:US
Practice Address - Phone:619-201-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst