Provider Demographics
NPI:1598404790
Name:SALLEY, ANNIE L
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:L
Last Name:SALLEY
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 1:2419 KEATON AVE APT I
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6741
Mailing Address - Country:US
Mailing Address - Phone:704-634-2665
Mailing Address - Fax:
Practice Address - Street 1:2419 KEATON AVE APT I
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6741
Practice Address - Country:US
Practice Address - Phone:704-634-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst