Provider Demographics
NPI:1639632102
Name:OTHMAN, TINA MARIE (MA,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:OTHMAN
Suffix:
Gender:F
Credentials:MA,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5727 AUTUMN CHASE CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-8173
Mailing Address - Country:US
Mailing Address - Phone:407-389-9294
Mailing Address - Fax:
Practice Address - Street 1:1297 US 27 N
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7907
Practice Address - Country:US
Practice Address - Phone:914-701-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7575235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist