Provider Demographics
NPI:1740539261
Name:RACINE, TINA MARIE (COTA/L)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:RACINE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-1917
Mailing Address - Country:US
Mailing Address - Phone:518-312-3628
Mailing Address - Fax:
Practice Address - Street 1:26 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143-1917
Practice Address - Country:US
Practice Address - Phone:518-312-3628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003383-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant