Provider Demographics
NPI:1447721949
Name:ORTOLAN, TINA KAY (SLP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:KAY
Last Name:ORTOLAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48363-1402
Mailing Address - Country:US
Mailing Address - Phone:832-215-1282
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3258
Practice Address - Country:US
Practice Address - Phone:734-323-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004527235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist