Provider Demographics
NPI:1598946519
Name:SHORT, TONYA GAMMAGE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:GAMMAGE
Last Name:SHORT
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:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-4950
Mailing Address - Country:US
Mailing Address - Phone:662-719-9231
Mailing Address - Fax:
Practice Address - Street 1:1111 OLD HWY. 61 NORTH
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-4950
Practice Address - Country:US
Practice Address - Phone:662-719-9231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS2971OtherMS DEPT. HEALTH