Provider Demographics
NPI:1134815913
Name:MINCHELLA, TINA DANIELLE (LAC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:DANIELLE
Last Name:MINCHELLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10932 E CATALINA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-7612
Mailing Address - Country:US
Mailing Address - Phone:480-586-4621
Mailing Address - Fax:
Practice Address - Street 1:2340 W RAY RD STE 2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3632
Practice Address - Country:US
Practice Address - Phone:201-975-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21410101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health