Provider Demographics
NPI:1417312950
Name:TALLY, MICHAEL ANN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANN
Last Name:TALLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 HIGHWAY 371 N
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-7274
Mailing Address - Country:US
Mailing Address - Phone:662-282-4949
Mailing Address - Fax:662-282-4955
Practice Address - Street 1:3077 HIGHWAY 371 N
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-7274
Practice Address - Country:US
Practice Address - Phone:662-282-4949
Practice Address - Fax:662-282-4955
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist