Provider Demographics
NPI:1457546780
Name:FRIEDMAN, TIA NICOLE (MA CFY-SLP)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:NICOLE
Last Name:FRIEDMAN
Suffix:
Gender:F
Credentials:MA CFY-SLP
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:NICOLE
Other - Last Name:HORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CFY-SLP
Mailing Address - Street 1:4016 RAINTREE RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3700
Mailing Address - Country:US
Mailing Address - Phone:757-488-2864
Mailing Address - Fax:757-488-4735
Practice Address - Street 1:4016 RAINTREE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3700
Practice Address - Country:US
Practice Address - Phone:757-488-2864
Practice Address - Fax:757-488-4735
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4309390200000X
VA2202005784235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004979061Medicaid
VA004979061Medicaid