Provider Demographics
NPI:1528562360
Name:DALY, TENNILLE FARRAH (MSPT)
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:FARRAH
Last Name:DALY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8809
Mailing Address - Country:US
Mailing Address - Phone:517-581-0262
Mailing Address - Fax:
Practice Address - Street 1:100 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1498
Practice Address - Country:US
Practice Address - Phone:517-205-7252
Practice Address - Fax:517-205-7253
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist