Healthcare Provider Details

I. General information

NPI: 1396708962
Provider Name (Legal Business Name): LORI A TUSSEY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 EDDINGTON DR
BLOOMINGTON IN
47401-8740
US

IV. Provider business mailing address

3626 EDDINGTON DR
BLOOMINGTON IN
47401-8740
US

V. Phone/Fax

Practice location:
  • Phone: 812-323-7185
  • Fax: 812-323-7185
Mailing address:
  • Phone: 812-323-7185
  • Fax: 812-323-7185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002231A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: