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NPI Code Detail

MEDICARE: SALLY M WAY TULLY

MEDICARE: SALLY M WAY TULLY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst1-13-12747

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11-13-12747OTHERBEHAVIOR ANALYST CERTIFICATION BOARD

General Provider Information

NPI Number : 1700127206
Entity Type Code : Organization
Provider Name (Legal Business Name) : SALLY M WAY TULLY
Provider Business Mailing Address
First Line : PO BOX 1822
Second Line :
City : RICHMOND HILL
State : GA
Zip : 31324-1822
Country : US
Telephone Number : 912-660-1100
Fax Number :
Provider Business Practice Location Address
First Line : 10164 FORD AVE STE D
Second Line :
City : RICHMOND HILL
State : GA
Zip : 31324-3948
Country : US
Telephone Number : 912-660-1100
Fax Number :
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : MRS. SALLY M WAY TULLY
Credential : BCBA
Telephone Number : 912-660-1100
Provider Enumeration Date : 03/07/2013
Last Update Date : 03/07/2013

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