Provider Demographics
NPI:1093205833
Name:TALLEY, MARRY IDELL (ASSOCIATES DEGREE)
Entity Type:Individual
Prefix:MRS
First Name:MARRY
Middle Name:IDELL
Last Name:TALLEY
Suffix:
Gender:F
Credentials:ASSOCIATES DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-2537
Mailing Address - Country:US
Mailing Address - Phone:937-263-8176
Mailing Address - Fax:937-263-8175
Practice Address - Street 1:1818 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-2537
Practice Address - Country:US
Practice Address - Phone:937-263-8176
Practice Address - Fax:937-263-8175
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator