Provider Demographics
NPI:1689395832
Name:PERRY, TINA (RBT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-1322
Mailing Address - Country:US
Mailing Address - Phone:605-281-2690
Mailing Address - Fax:
Practice Address - Street 1:6033 FASHION POINT DR
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4847
Practice Address - Country:US
Practice Address - Phone:801-549-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-22-231687106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician