Provider Demographics
NPI:1346372745
Name:POLKINGHORN, TANYA M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:POLKINGHORN
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 1:5608 W 51ST ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-1832
Mailing Address - Country:US
Mailing Address - Phone:605-366-8419
Mailing Address - Fax:
Practice Address - Street 1:1100 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6325
Practice Address - Country:US
Practice Address - Phone:605-782-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5832240Medicaid