Provider Demographics
NPI:1134538457
Name:TYLER-BOLTREK, EMMA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:TYLER-BOLTREK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 1/2 DON JUAN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2409
Mailing Address - Country:US
Mailing Address - Phone:505-570-9169
Mailing Address - Fax:
Practice Address - Street 1:826 CAMINO DEL MONTE REY
Practice Address - Street 2:SUITE A2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3977
Practice Address - Country:US
Practice Address - Phone:505-954-9940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5481235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist