Provider Demographics
NPI:1548708712
Name:STANFORD, TINA LOUISE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:STANFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:LOUISE
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2752 SARGENT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1568
Mailing Address - Country:US
Mailing Address - Phone:510-860-2474
Mailing Address - Fax:
Practice Address - Street 1:1109 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1418
Practice Address - Country:US
Practice Address - Phone:415-256-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN9903495101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor