Provider Demographics
NPI:1871190561
Name:TYE, BRIAN (SPEECH THERAPIST)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TYE
Suffix:
Gender:M
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 ROSWELL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6059
Mailing Address - Country:US
Mailing Address - Phone:706-331-0213
Mailing Address - Fax:
Practice Address - Street 1:1168 CHULIO RD SE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4084
Practice Address - Country:US
Practice Address - Phone:706-802-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005445235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist