Healthcare Provider Details

I. General information

NPI: 1417336835
Provider Name (Legal Business Name): TINA LEE DELAUGHTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E MAIN ST
GRASS VALLEY CA
95945-5208
US

IV. Provider business mailing address

11670 ATWOOD RD
AUBURN CA
95603-9522
US

V. Phone/Fax

Practice location:
  • Phone: 530-887-2800
  • Fax:
Mailing address:
  • Phone: 530-477-9518
  • Fax: 530-889-8169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number66402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: