Provider Demographics
NPI:1649579244
Name:BOLYARD, TINA (MNS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:MNS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 E MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-4244
Mailing Address - Country:US
Mailing Address - Phone:602-748-9927
Mailing Address - Fax:
Practice Address - Street 1:642 E MEADOW LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-4244
Practice Address - Country:US
Practice Address - Phone:602-748-9927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1784235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist