Provider Demographics
NPI:1992907869
Name:TINNEY, MARY BETH (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:TINNEY
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:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:LEIVASY
Mailing Address - State:WV
Mailing Address - Zip Code:26676-0131
Mailing Address - Country:US
Mailing Address - Phone:304-846-2077
Mailing Address - Fax:
Practice Address - Street 1:400 OLD MAIN DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1360
Practice Address - Country:US
Practice Address - Phone:304-872-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSLP-1066OtherLICENSURE