Provider Demographics
NPI:1407347826
Name:TUSSON, MARY ELISE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELISE
Last Name:TUSSON
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 1:290 N FLANAGIN LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5058
Mailing Address - Country:US
Mailing Address - Phone:479-719-7399
Mailing Address - Fax:
Practice Address - Street 1:2811 W HUNTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-7736
Practice Address - Country:US
Practice Address - Phone:479-750-8854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR200216235Z00000X
AR200061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist