Provider Demographics
NPI:1912166158
Name:DESPORT, TINA MARIE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:DESPORT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:PA
Mailing Address - Zip Code:15627-2686
Mailing Address - Country:US
Mailing Address - Phone:724-244-7784
Mailing Address - Fax:724-537-0780
Practice Address - Street 1:1001 LIGONIER ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1832
Practice Address - Country:US
Practice Address - Phone:724-537-0760
Practice Address - Fax:724-537-0780
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW129788101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health