Provider Demographics
NPI:1982217360
Name:TEAGUE, TIA KAITLYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TIA
Middle Name:KAITLYN
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:TIA
Other - Middle Name:KAITLYN
Other - Last Name:MCCUTCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TIA MCCUTCHEN
Mailing Address - Street 1:1001 HIGHWAY 96 SW
Mailing Address - Street 2:
Mailing Address - City:LAVACA
Mailing Address - State:AR
Mailing Address - Zip Code:72941-3921
Mailing Address - Country:US
Mailing Address - Phone:479-208-2288
Mailing Address - Fax:
Practice Address - Street 1:102 N OAK ST
Practice Address - Street 2:
Practice Address - City:HACKETT
Practice Address - State:AR
Practice Address - Zip Code:72937-4756
Practice Address - Country:US
Practice Address - Phone:479-638-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR201180235Z00000X
AR201525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist