Provider Demographics
NPI:1912367004
Name:ENDSLEY, TINA ROSE (MA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ROSE
Last Name:ENDSLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:RIGDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:LIFESTANCE
Mailing Address - Street 2:12636 SE STARK ST UNIT J
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LIFESTANCE HEALTH
Practice Address - Street 2:860 82ND DRIVE
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-3880
Practice Address - Country:US
Practice Address - Phone:503-253-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7453101YA0400X, 101YM0800X
IN39003428A101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health