Provider Demographics
NPI:1023109808
Name:TISDALE, FREDDY G (MA CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:FREDDY
Middle Name:G
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W FLORIDA ST
Mailing Address - Street 2:SUITE 200 JEFFERSON SPEECH & LANGUAGE CENTER OF ST TAMM
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448
Mailing Address - Country:US
Mailing Address - Phone:985-626-8403
Mailing Address - Fax:985-727-9871
Practice Address - Street 1:255 W FLORIDA ST
Practice Address - Street 2:SUITE 200 JEFFERSON SPEECH & LANGUAGE CENTER OF ST TAMM
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448
Practice Address - Country:US
Practice Address - Phone:985-626-8403
Practice Address - Fax:985-727-9871
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12008332235Z00000X
LA4135235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist