Provider Demographics
NPI:1821216599
Name:TOLLEY, DEMETRA G (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DEMETRA
Middle Name:G
Last Name:TOLLEY
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 1:3900E 750S
Mailing Address - Street 2:
Mailing Address - City:FT. BRANCH
Mailing Address - State:IN
Mailing Address - Zip Code:47648
Mailing Address - Country:US
Mailing Address - Phone:812-205-6341
Mailing Address - Fax:
Practice Address - Street 1:3900E 750S
Practice Address - Street 2:
Practice Address - City:FT. BRANCH
Practice Address - State:IN
Practice Address - Zip Code:47648
Practice Address - Country:US
Practice Address - Phone:812-205-6341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003470A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist