Provider Demographics
NPI:1093895310
Name:WATSON WIENS, TINA (MA, LMFT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WATSON WIENS
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1503
Mailing Address - Country:US
Mailing Address - Phone:651-642-9317
Mailing Address - Fax:651-642-1908
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-642-9317
Practice Address - Fax:651-642-1908
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1158106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP55646OtherHEALTHPARTNERS
MN82G45WIOtherBLUE CROSS BLUE SHIELD