Provider Demographics
NPI:1124054804
Name:DALE, TINA M (LCSW)
Entity type:Individual
Prefix:MISS
First Name:TINA
Middle Name:M
Last Name:DALE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8420 DELMAR BLVD STE 209
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2177
Mailing Address - Country:US
Mailing Address - Phone:314-477-8751
Mailing Address - Fax:314-983-0331
Practice Address - Street 1:8420 DELMAR BLVD STE 209
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2177
Practice Address - Country:US
Practice Address - Phone:314-477-8751
Practice Address - Fax:314-983-0331
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040100981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
190570OtherBLUE CROSS BLUE SHIELD, A
1133370OtherCAQH PROVIDER NUMBER