Provider Demographics
NPI:1497235691
Name:ANTONISSE-IRWIN, TANYA JEAN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:JEAN
Last Name:ANTONISSE-IRWIN
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 1:1023 KIMBRO DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126
Mailing Address - Country:US
Mailing Address - Phone:972-948-3852
Mailing Address - Fax:
Practice Address - Street 1:1023 KIMBRO DRIVE
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126
Practice Address - Country:US
Practice Address - Phone:972-948-3852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist