Healthcare Provider Details

I. General information

NPI: 1386225712
Provider Name (Legal Business Name): PETTY TINEO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2021
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORMAL AVE
MONTCLAIR NJ
07043-1626
US

IV. Provider business mailing address

1 NORMAL AVE
MONTCLAIR NJ
07043-1626
US

V. Phone/Fax

Practice location:
  • Phone: 551-795-2266
  • Fax:
Mailing address:
  • Phone: 551-795-2266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number027342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: