Provider Demographics
NPI:1578701371
Name:IM, TINA LY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LY
Last Name:IM
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 1:1615 COMMONWEALTH AVE
Mailing Address - Street 2:APT. 11
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4213
Mailing Address - Country:US
Mailing Address - Phone:626-840-0010
Mailing Address - Fax:
Practice Address - Street 1:1615 COMMONWEALTH AVE
Practice Address - Street 2:APT. 11
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-4213
Practice Address - Country:US
Practice Address - Phone:626-840-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist