Provider Demographics
NPI:1689217655
Name:BUBB, TINA BEATRICE (MA, LAC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:BEATRICE
Last Name:BUBB
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 MONTICELLO AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-5524
Mailing Address - Country:US
Mailing Address - Phone:212-470-9041
Mailing Address - Fax:
Practice Address - Street 1:1139 E JERSEY ST STE 417
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2446
Practice Address - Country:US
Practice Address - Phone:908-622-3200
Practice Address - Fax:908-622-3202
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00475900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health