Healthcare Provider Details

I. General information

NPI: 1609716273
Provider Name (Legal Business Name): TINA HADEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 E WALNUT ST STE C-120
COLUMBIA MO
65201-6428
US

IV. Provider business mailing address

2130 E HAMILTON CT APT A108
REPUBLIC MO
65738-1548
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 435-218-1417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: