Provider Demographics
NPI:1255368841
Name:ANDERSEN, TINA (MS/CCC-A)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MS/CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:631-582-3707
Mailing Address - Fax:631-582-3795
Practice Address - Street 1:1832 VETERANS MEMORIAL HWY.
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749
Practice Address - Country:US
Practice Address - Phone:631-582-3707
Practice Address - Fax:631-582-3795
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1594-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM25141Medicare PIN