Provider Demographics
NPI:1114225562
Name:TANIS, REBECCA NIELSEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:NIELSEN
Last Name:TANIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 W SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6321
Mailing Address - Country:US
Mailing Address - Phone:231-838-9203
Mailing Address - Fax:
Practice Address - Street 1:1319 W SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6321
Practice Address - Country:US
Practice Address - Phone:231-838-9203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist