Provider Demographics
NPI:1407090582
Name:WYMAN, TAMARA LEE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LEE
Last Name:WYMAN
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 1:2206 MITCHELL ST.
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8674
Mailing Address - Country:US
Mailing Address - Phone:231-348-7777
Mailing Address - Fax:231-348-3177
Practice Address - Street 1:2206 MITCHELL PARK DR
Practice Address - Street 2:UNIT 14
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8674
Practice Address - Country:US
Practice Address - Phone:231-348-7777
Practice Address - Fax:231-348-3177
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP61310OtherPTAN