Provider Demographics
NPI:1982896379
Name:VAN HORN, TINA MICHELL (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MICHELL
Last Name:VAN HORN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 N NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:CHOUTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74337-3770
Mailing Address - Country:US
Mailing Address - Phone:918-640-6468
Mailing Address - Fax:
Practice Address - Street 1:510 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-6411
Practice Address - Country:US
Practice Address - Phone:918-640-6468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3168235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200028820 AMedicaid