Provider Demographics
NPI:1033666839
Name:TABLE TALK
Entity Type:Organization
Organization Name:TABLE TALK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR/PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:LENE
Authorized Official - Last Name:DASH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:770-990-6420
Mailing Address - Street 1:47 S CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-6416
Mailing Address - Country:US
Mailing Address - Phone:770-990-6420
Mailing Address - Fax:
Practice Address - Street 1:47 S CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-6416
Practice Address - Country:US
Practice Address - Phone:770-990-6420
Practice Address - Fax:217-274-7202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006014251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health