Provider Demographics
NPI:1700289360
Name:SURGULADZE, TINATIN (DHD)
Entity Type:Individual
Prefix:MS
First Name:TINATIN
Middle Name:
Last Name:SURGULADZE
Suffix:
Gender:F
Credentials:DHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BURGESS RD
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:RI
Mailing Address - Zip Code:02825
Mailing Address - Country:US
Mailing Address - Phone:857-333-0533
Mailing Address - Fax:
Practice Address - Street 1:205 WATERMAN ST SUITE 106
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:857-333-0533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MA11259103T00000X
RIPS01795103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor