Provider Demographics
NPI:1629548805
Name:BYRD, TINA MARIE (CPED, CMF)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BYRD
Suffix:
Gender:F
Credentials:CPED, CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 S US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-3299
Mailing Address - Country:US
Mailing Address - Phone:812-482-6922
Mailing Address - Fax:812-482-6923
Practice Address - Street 1:397 S US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-3299
Practice Address - Country:US
Practice Address - Phone:812-482-6922
Practice Address - Fax:812-482-6923
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC52837224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter