Provider Demographics
NPI:1801034053
Name:WARD, TALLY MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TALLY
Middle Name:MARIE
Last Name:WARD
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 1:200 N I 35 STE C
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-4241
Mailing Address - Country:US
Mailing Address - Phone:469-917-0805
Mailing Address - Fax:469-917-0799
Practice Address - Street 1:200 N I 35 STE C
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-4241
Practice Address - Country:US
Practice Address - Phone:469-917-0805
Practice Address - Fax:469-917-0799
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106232235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286230202Medicaid