Provider Demographics
NPI:1760595300
Name:OTTMAN-BOYKIN, TINA MARIE (MSE LCSW LPC NCC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:OTTMAN-BOYKIN
Suffix:
Gender:F
Credentials:MSE LCSW LPC NCC
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:OTTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2209 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-4281
Mailing Address - Country:US
Mailing Address - Phone:920-892-7606
Mailing Address - Fax:920-892-7606
Practice Address - Street 1:2209 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-4281
Practice Address - Country:US
Practice Address - Phone:920-892-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1568125101YP2500X
WI28861231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
138002OtherCHAMPUS TRICARE
WI39744000Medicaid
138002OtherCHAMPUS TRICARE