Provider Demographics
NPI:1386793248
Name:BAETEN, TINA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:TINA MARIE
Middle Name:
Last Name:BAETEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-9116
Mailing Address - Country:US
Mailing Address - Phone:904-605-4986
Mailing Address - Fax:941-460-5599
Practice Address - Street 1:2920 S WEBSTER AVE STE B
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1594
Practice Address - Country:US
Practice Address - Phone:920-632-4471
Practice Address - Fax:920-632-4315
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13791101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39382000Medicaid