Provider Demographics
NPI:1386062545
Name:COTTO, TINA (LICDC)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:COTTO
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:MICHELLE
Other - Last Name:COTTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICDC
Mailing Address - Street 1:3107 HEATHER GLEN CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1891
Mailing Address - Country:US
Mailing Address - Phone:937-717-1419
Mailing Address - Fax:
Practice Address - Street 1:904 SCIOTO ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-2226
Practice Address - Country:US
Practice Address - Phone:937-653-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH111069101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)