Provider Demographics
NPI:1588910624
Name:BOSTIC, TINA D (MFT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:D
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3154 FAIRMEDE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-2765
Mailing Address - Country:US
Mailing Address - Phone:510-672-6166
Mailing Address - Fax:
Practice Address - Street 1:3154 FAIRMEDE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-2765
Practice Address - Country:US
Practice Address - Phone:510-672-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist