Provider Demographics
NPI:1386910719
Name:TAM, ALICIA MARLEEN (MS CF-SLP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARLEEN
Last Name:TAM
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2579 S 500 E
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8422
Mailing Address - Country:US
Mailing Address - Phone:574-339-9075
Mailing Address - Fax:
Practice Address - Street 1:9909 E 100 S
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-9163
Practice Address - Country:US
Practice Address - Phone:765-628-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002214A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist