Provider Demographics
NPI:1669026761
Name:VYAS, TINA (ATC/L, CSCS, CPT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:VYAS
Suffix:
Gender:F
Credentials:ATC/L, CSCS, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2648
Mailing Address - Country:US
Mailing Address - Phone:321-543-1686
Mailing Address - Fax:
Practice Address - Street 1:1802 PINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2648
Practice Address - Country:US
Practice Address - Phone:321-543-1686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL41142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer