Healthcare Provider Details

I. General information

NPI: 1518275130
Provider Name (Legal Business Name): TINA WIBSTAD LCSW, LSSW, CADC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SINA WIBSTAD LCSW, LSSW, CADC III

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 A ST
SPRINGFIELD OR
97477-4609
US

IV. Provider business mailing address

906 MAIN AVE
TILLAMOOK OR
97141-3816
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-3331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12-06-70
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL5975
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number509692
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number10517192
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: