Provider Demographics
NPI:1013210194
Name:TALAPATRA, POORVA (MED, LCPC)
Entity Type:Individual
Prefix:
First Name:POORVA
Middle Name:
Last Name:TALAPATRA
Suffix:
Gender:F
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:109 CALIFORNIA ST
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:400 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9900
Practice Address - Fax:618-529-1384
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178005097101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854024Medicaid