Provider Demographics
NPI:1821614496
Name:TULLY, MCKAYLA (MA, CCC - SLP)
Entity Type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:
Last Name:TULLY
Suffix:
Gender:F
Credentials:MA, CCC - SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10038 E TROON NORTH DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-4569
Mailing Address - Country:US
Mailing Address - Phone:602-370-5328
Mailing Address - Fax:
Practice Address - Street 1:280 S EVERGREEN RD UNIT 1384
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85288-5093
Practice Address - Country:US
Practice Address - Phone:602-370-5328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP10641235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty