Provider Demographics
NPI:1770823064
Name:ABBOTT, TINA MARIE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1135 BOATMAN RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16928-9622
Mailing Address - Country:US
Mailing Address - Phone:814-326-4795
Mailing Address - Fax:
Practice Address - Street 1:1 DORSETT DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:PA
Practice Address - Zip Code:16933-1517
Practice Address - Country:US
Practice Address - Phone:570-662-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW126999104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker