Provider Demographics
NPI:1336267764
Name:TANIS, DELAINE THIELE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DELAINE
Middle Name:THIELE
Last Name:TANIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 BILLETTS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27921-7505
Mailing Address - Country:US
Mailing Address - Phone:252-336-9957
Mailing Address - Fax:252-337-7928
Practice Address - Street 1:207 BILLETTS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NC
Practice Address - Zip Code:27921-7505
Practice Address - Country:US
Practice Address - Phone:252-336-9957
Practice Address - Fax:252-337-7928
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3186235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist