Provider Demographics
NPI:1871889410
Name:WAY-TULLY, SALLY M (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:M
Last Name:WAY-TULLY
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10164 FORD AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-3949
Mailing Address - Country:US
Mailing Address - Phone:912-660-1100
Mailing Address - Fax:
Practice Address - Street 1:10164 FORD AVE
Practice Address - Street 2:SUITE D
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3949
Practice Address - Country:US
Practice Address - Phone:912-660-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-13-12747103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst