MEDICARE: BRIAN TYE SPEECH THERAPIST

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	SLP005445	GA

General Provider Information

NPI Number	:	1871190561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN TYE SPEECH THERAPIST

Provider Business Mailing Address
First Line	:	309 ROSWELL AVE SE
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-6059
Country	:	US
Telephone Number	:	706-331-0213
Fax Number	:

Provider Business Practice Location Address
First Line	:	1168 CHULIO RD SE
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-4084
Country	:	US
Telephone Number	:	706-802-0990
Fax Number	:

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

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

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Directions to “ BRIAN TYE SPEECH THERAPIST” Practice Location

Language	Start Address	Practice Location

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