Healthcare Provider Details

I. General information

NPI: 1386931152
Provider Name (Legal Business Name): TATIANA MIJAC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PINE CONE DR
PALM COAST FL
32164-8423
US

IV. Provider business mailing address

PO BOX 352530
PALM COAST FL
32135-2530
US

V. Phone/Fax

Practice location:
  • Phone: 386-446-7796
  • Fax:
Mailing address:
  • Phone: 386-446-7796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP8105
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: