Provider Demographics
NPI:1659562353
Name:TALLEY, TYRA (PT)
Entity Type:Individual
Prefix:MS
First Name:TYRA
Middle Name:
Last Name:TALLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 SOUTHBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-5129
Mailing Address - Country:US
Mailing Address - Phone:843-292-8499
Mailing Address - Fax:
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-777-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist