Provider Demographics
NPI:1043399496
Name:VELLIQUETTE, TAMMY L (MED CCC SLP L)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:L
Last Name:VELLIQUETTE
Suffix:
Gender:F
Credentials:MED CCC SLP L
Other - Prefix:MS
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:PETO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED CCC SLP L
Mailing Address - Street 1:PO BOX 6336
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154-0023
Mailing Address - Country:US
Mailing Address - Phone:404-934-0605
Mailing Address - Fax:770-577-2816
Practice Address - Street 1:6732 SPRING ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1760
Practice Address - Country:US
Practice Address - Phone:404-934-0605
Practice Address - Fax:770-577-2816
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004538235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01089131OtherASHA
GA00839781CMedicaid
GASLP004538OtherGEORGIA STATE LICENSE