Provider Demographics
NPI:1700193190
Name:TULLY, DAPHNE (SLP)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8645 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9780
Mailing Address - Country:US
Mailing Address - Phone:315-963-0864
Mailing Address - Fax:
Practice Address - Street 1:216 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3229
Practice Address - Country:US
Practice Address - Phone:315-963-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007508-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist