Provider Demographics
NPI:1518140763
Name:DISMUKE, TINIKA ROSS (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TINIKA
Middle Name:ROSS
Last Name:DISMUKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7544 METCALF RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-8638
Mailing Address - Country:US
Mailing Address - Phone:229-379-6456
Mailing Address - Fax:229-226-6353
Practice Address - Street 1:7544 METCALF RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-8638
Practice Address - Country:US
Practice Address - Phone:229-379-6456
Practice Address - Fax:229-226-6353
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA177434204CMedicaid
GA177434204DMedicaid