Provider Demographics
NPI:1770570137
Name:SOOTS, TINA (OTRL)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SOOTS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PCS 9 BOX 3674
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09123-0068
Mailing Address - Country:US
Mailing Address - Phone:0049656-561-8238
Mailing Address - Fax:
Practice Address - Street 1:PCS 9 UNIT 3620
Practice Address - Street 2:UNIT 3620
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09123-0068
Practice Address - Country:US
Practice Address - Phone:0049656-561-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL-0005221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist