Provider Demographics
NPI:1063021368
Name:TALLON, SAMANTHA DANIELLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DANIELLE
Last Name:TALLON
Suffix:
Gender:F
Credentials:
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 4741
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4741
Mailing Address - Country:US
Mailing Address - Phone:209-900-2371
Mailing Address - Fax:
Practice Address - Street 1:1101 M ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0755
Practice Address - Country:US
Practice Address - Phone:209-522-9568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137293106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist