1043399496 NPI number — MS. TAMMY L VELLIQUETTE M.ED. CCC SLP L

Table of content: MS. TAMMY L VELLIQUETTE M.ED. CCC SLP L (NPI 1043399496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043399496 NPI number — MS. TAMMY L VELLIQUETTE M.ED. CCC SLP L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VELLIQUETTE
Provider First Name:
TAMMY
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED. CCC SLP L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETO
Provider Other First Name:
TAMMY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.ED. CCC SLP L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043399496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6336
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30154-0023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-934-0605
Provider Business Mailing Address Fax Number:
770-577-2816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6732 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-1760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-934-0605
Provider Business Practice Location Address Fax Number:
770-577-2816
Provider Enumeration Date:
11/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP004538 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01089131 . This is a "ASHA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00839781C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: SLP004538 . This is a "GEORGIA STATE LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".