Provider Demographics
NPI:1891044582
Name:MARTIN, TYNA LYNDELLE
Entity Type:Individual
Prefix:MS
First Name:TYNA
Middle Name:LYNDELLE
Last Name:MARTIN
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 1:208 S SEBA SCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:AR
Mailing Address - Zip Code:72944-2943
Mailing Address - Country:US
Mailing Address - Phone:479-206-4615
Mailing Address - Fax:
Practice Address - Street 1:900 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2617
Practice Address - Country:US
Practice Address - Phone:918-649-0772
Practice Address - Fax:918-649-0071
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health