Provider Demographics
NPI:1023058625
Name:SOUTHWORTH, TINA MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-3838
Mailing Address - Country:US
Mailing Address - Phone:918-696-7220
Mailing Address - Fax:918-696-7479
Practice Address - Street 1:519 N 2ND ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-2407
Practice Address - Country:US
Practice Address - Phone:918-696-7220
Practice Address - Fax:918-696-7479
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor