Provider Demographics
NPI:1093969719
Name:GREEN, TINA J (SLP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 HULEN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-6808
Mailing Address - Country:US
Mailing Address - Phone:817-377-2535
Mailing Address - Fax:817-292-0572
Practice Address - Street 1:3550 HULEN ST
Practice Address - Street 2:SUITE D
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-6808
Practice Address - Country:US
Practice Address - Phone:817-377-2535
Practice Address - Fax:817-292-0572
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist