Provider Demographics
NPI:1639641194
Name:TYSON, STEPHANIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TYSON
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 1:619 NORMANDIE BLVD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1547
Mailing Address - Country:US
Mailing Address - Phone:419-352-9156
Mailing Address - Fax:
Practice Address - Street 1:100 TIGER TRL
Practice Address - Street 2:
Practice Address - City:LIBERTY CENTER
Practice Address - State:OH
Practice Address - Zip Code:43532-9642
Practice Address - Country:US
Practice Address - Phone:419-533-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist