Provider Demographics
NPI:1730226168
Name:TATUM-RILEY, LINDA (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:
Last Name:TATUM-RILEY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:TATUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:PO BOX 555907
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32855-5907
Mailing Address - Country:US
Mailing Address - Phone:407-298-5300
Mailing Address - Fax:407-296-0026
Practice Address - Street 1:6388 SILVER STAR RD
Practice Address - Street 2:SUITE 2E
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3235
Practice Address - Country:US
Practice Address - Phone:407-298-5300
Practice Address - Fax:407-296-0026
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 1245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202579OtherAMERIGROUP PROVIDER NUMBE
FL18348OtherSTAYWELL PROVIDER NUMBER