Provider Demographics
NPI:1659730117
Name:TYUS, KELLY VICTORIA (CCC-A)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:VICTORIA
Last Name:TYUS
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD
Mailing Address - Street 2:SUITE 202-A
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2379
Mailing Address - Country:US
Mailing Address - Phone:615-851-3901
Mailing Address - Fax:615-447-3612
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD
Practice Address - Street 2:SUITE 202-A
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2379
Practice Address - Country:US
Practice Address - Phone:615-851-3901
Practice Address - Fax:615-447-3612
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSLPAUD00218466231H00000X
TN577237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist