MEDICARE: MS. TINA CATHERINE FRIEND MCD 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	SLP005499	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	341976	OTHER	GA	WELLCARE CMO #

General Provider Information

NPI Number	:	1053315895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA CATHERINE FRIEND MCD CCC-SLP

Provider Business Mailing Address
First Line	:	55 ROBERTA RD
Second Line	:
City	:	MANCHESTER
State	:	GA
Zip	:	31816-6501
Country	:	US
Telephone Number	:	706-575-5396
Fax Number	:	706-846-9238

Provider Business Practice Location Address
First Line	:	55 ROBERTA RD
Second Line	:
City	:	MANCHESTER
State	:	GA
Zip	:	31816-6501
Country	:	US
Telephone Number	:	706-575-5396
Fax Number	:	706-846-9238

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/09/2007

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Directions to “ MS. TINA CATHERINE FRIEND MCD CCC-SLP” Practice Location

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