Provider Demographics
NPI:1639379035
Name:TMJ TX CLINIC
Entity Type:Organization
Organization Name:TMJ TX CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS/CCC/SLP
Authorized Official - Phone:727-843-4035
Mailing Address - Street 1:8649 REGENCY PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-5742
Mailing Address - Country:US
Mailing Address - Phone:727-843-4035
Mailing Address - Fax:727-817-0475
Practice Address - Street 1:8649 REGENCY PARK BLVD
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-5742
Practice Address - Country:US
Practice Address - Phone:727-843-4035
Practice Address - Fax:727-817-0475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1638235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty