Provider Demographics
NPI:1831564236
Name:TIEBOUT, DANA MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:TIEBOUT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:MARIE
Other - Last Name:ANDREOLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:43 CRYSTAL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-2165
Mailing Address - Country:US
Mailing Address - Phone:203-804-4355
Mailing Address - Fax:
Practice Address - Street 1:247 RHODES RD
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3568
Practice Address - Country:US
Practice Address - Phone:860-870-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004894235Z00000X
MA9516235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist