Provider Demographics
NPI:1053315895
Name:FRIEND, TINA CATHERINE (MCD CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:CATHERINE
Last Name:FRIEND
Suffix:
Gender:F
Credentials:MCD CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 ROBERTA RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31816-6501
Mailing Address - Country:US
Mailing Address - Phone:706-575-5396
Mailing Address - Fax:706-846-9238
Practice Address - Street 1:55 ROBERTA RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:GA
Practice Address - Zip Code:31816-6501
Practice Address - Country:US
Practice Address - Phone:706-575-5396
Practice Address - Fax:706-846-9238
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA341976OtherWELLCARE CMO #