MEDICARE: STEPHANIE TYSON M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	10042	OH

General Provider Information

NPI Number	:	1639641194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE TYSON M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	619 NORMANDIE BLVD
Second Line	:
City	:	BOWLING GREEN
State	:	OH
Zip	:	43402-1547
Country	:	US
Telephone Number	:	419-352-9156
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 TIGER TRL
Second Line	:
City	:	LIBERTY CENTER
State	:	OH
Zip	:	43532-9642
Country	:	US
Telephone Number	:	419-533-2604
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2018
Last Update Date	:	12/21/2018

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