Provider Demographics
NPI:1700930443
Name:BAYLESS, TERESA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:BAYLESS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2507
Mailing Address - Country:US
Mailing Address - Phone:229-253-8500
Mailing Address - Fax:229-253-8522
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2507
Practice Address - Country:US
Practice Address - Phone:229-253-8500
Practice Address - Fax:229-253-8522
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581921576OtherFTIN
GA000802447AMedicaid
GA52446988OtherBLUE CROSS BLUE SHIELD