Basic Information
| Provider Information | |||||||||
| NPI: | 1346419959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COREY | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W., L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973553109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414515932 | ||||||||
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| Practice Location | |||||||||
| Address1: | 706 S I ST | ||||||||
| Address2: | |||||||||
| City: | LAKEVIEW | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976301622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419476021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 05/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | L5327 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 500698737 | 05 | OR | MEDICAID |