Provider Demographics
NPI:1639312010
Name:CLUMPNER, TINA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CLUMPNER
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:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-0568
Mailing Address - Country:US
Mailing Address - Phone:907-512-0979
Mailing Address - Fax:907-512-3023
Practice Address - Street 1:104 CENTER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6393
Practice Address - Country:US
Practice Address - Phone:907-512-0979
Practice Address - Fax:907-512-3023
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKSLP S 270235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP0004Medicaid