Provider Demographics
NPI:1700019403
Name:MILLIS, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MILLIS
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 1:3315 AIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2005
Mailing Address - Country:US
Mailing Address - Phone:707-523-2242
Mailing Address - Fax:707-526-3817
Practice Address - Street 1:3315 AIRWAY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2005
Practice Address - Country:US
Practice Address - Phone:707-523-2242
Practice Address - Fax:707-526-3817
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)