Provider Demographics
NPI:1225150360
Name:WAILGUM, TINA DEAN
Entity Type:Individual
Prefix:PROF
First Name:TINA
Middle Name:DEAN
Last Name:WAILGUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1115
Mailing Address - Country:US
Mailing Address - Phone:610-454-1315
Mailing Address - Fax:
Practice Address - Street 1:601 MAIN ST.
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-1000
Practice Address - Country:US
Practice Address - Phone:610-409-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART000191A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer