Provider Demographics
NPI:1053549675
Name:ANDERSON, TINA MARIA (MA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 JORDAN ST
Mailing Address - Street 2:STE 510 B
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4518
Mailing Address - Country:US
Mailing Address - Phone:318-429-4377
Mailing Address - Fax:318-429-4389
Practice Address - Street 1:820 JORDAN ST
Practice Address - Street 2:STE 510 B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4518
Practice Address - Country:US
Practice Address - Phone:318-429-4377
Practice Address - Fax:318-429-4389
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor