Provider Demographics
NPI:1427465376
Name:ANCTIL, TINA MARIE (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:ANCTIL
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SW 11TH AVE
Mailing Address - Street 2:SUITE 509
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2125
Mailing Address - Country:US
Mailing Address - Phone:503-343-9838
Mailing Address - Fax:503-926-9109
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:SUITE 509
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2125
Practice Address - Country:US
Practice Address - Phone:503-343-9838
Practice Address - Fax:503-926-9109
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2429101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health