Provider Demographics
NPI:1992864110
Name:VANDEGRIFT, TINEKE CARMAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TINEKE
Middle Name:CARMAN
Last Name:VANDEGRIFT
Suffix:
Gender:F
Credentials:PSYD
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 664
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-0664
Mailing Address - Country:US
Mailing Address - Phone:978-263-1611
Mailing Address - Fax:978-776-2321
Practice Address - Street 1:30 DOMINO DR STE 2
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2802
Practice Address - Country:US
Practice Address - Phone:978-263-1611
Practice Address - Fax:978-776-2321
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7174103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05812OtherBLUE CROSS BLUE SHIELD
MA250942000OtherMAGELLAN
MAW05812OtherBLUE CROSS BLUE SHIELD