Provider Demographics
NPI:1205274016
Name:FRALIX, JEREMY RAY (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:RAY
Last Name:FRALIX
Suffix:
Gender:M
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 1:1264 E COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4540
Mailing Address - Country:US
Mailing Address - Phone:931-698-0976
Mailing Address - Fax:
Practice Address - Street 1:1264 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4540
Practice Address - Country:US
Practice Address - Phone:931-698-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist