Provider Demographics
NPI:1134394935
Name:VAN WYHE, TINA MARIE (DT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:VAN WYHE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27410 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:BEECHER
Mailing Address - State:IL
Mailing Address - Zip Code:60401-3497
Mailing Address - Country:US
Mailing Address - Phone:708-946-6096
Mailing Address - Fax:708-946-2895
Practice Address - Street 1:27410 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:BEECHER
Practice Address - State:IL
Practice Address - Zip Code:60401-3497
Practice Address - Country:US
Practice Address - Phone:708-946-6096
Practice Address - Fax:708-946-2895
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILTP97450200P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist