Provider Demographics
NPI:1275253007
Name:TYGARD, TIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:TYGARD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1163 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-1791
Mailing Address - Country:US
Mailing Address - Phone:801-661-9088
Mailing Address - Fax:
Practice Address - Street 1:1163 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-1791
Practice Address - Country:US
Practice Address - Phone:801-661-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14096425235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14096425OtherAMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION
UT11111257-4102OtherDEPARTMENT OF PROFESSIONAL LICENSURE