Provider Demographics
NPI:1881973170
Name:BONI, TINA MICHELLE (MA, PSYD)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MICHELLE
Last Name:BONI
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 INGA ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37206-3314
Mailing Address - Country:US
Mailing Address - Phone:412-916-8852
Mailing Address - Fax:
Practice Address - Street 1:545 MAINSTREAM DR STE 110
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1256
Practice Address - Country:US
Practice Address - Phone:412-916-8852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001420103K00000X
TN3599103TC2200X
TNLPC0000004430101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007288440027Medicaid
PA328834A336347OtherVALUE BEHAVIORAL HEALTH