Provider Demographics
NPI:1902013808
Name:JOHN, TINA J
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:J
Last Name:JOHN
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:PO BOX 2622
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-2622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 OJO COURT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-564-4804
Practice Address - Fax:505-564-4857
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0081491101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)