Provider Demographics
NPI:1801937693
Name:VERMEULEN, TINA (MS)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:VERMEULEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 W MEAD DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5521
Mailing Address - Country:US
Mailing Address - Phone:480-857-7384
Mailing Address - Fax:
Practice Address - Street 1:8115 E INDIAN BEND RD
Practice Address - Street 2:SUITE 123
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-4819
Practice Address - Country:US
Practice Address - Phone:480-951-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP5331235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ172046Medicare ID - Type UnspecifiedAHCCCS PROVIDER ID