Healthcare Provider Details

I. General information

NPI: 1265607790
Provider Name (Legal Business Name): ERICA TULLOS PETERSON CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERICA TULLOS

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 HIGHWAY 80 E SUITES 10 & 11
CLINTON MS
39056
US

IV. Provider business mailing address

921 W BEACON STREET
PHILADELPHIA MS
39350
US

V. Phone/Fax

Practice location:
  • Phone: 601-460-0910
  • Fax: 601-460-0911
Mailing address:
  • Phone: 601-650-0002
  • Fax: 601-650-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS3095
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS-3095
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: