Provider Demographics
NPI:1124250329
Name:ALLIS, TINA L (SLP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:ALLIS
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 1:1559 TIMBERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-6935
Mailing Address - Country:US
Mailing Address - Phone:434-616-0567
Mailing Address - Fax:434-582-4533
Practice Address - Street 1:1559 TIMBERLAKE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-6935
Practice Address - Country:US
Practice Address - Phone:434-582-4533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004828235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15436342OtherCAQH