Provider Demographics
NPI:1235405259
Name:BRACKEN, TALAISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:TALAISHA
Middle Name:
Last Name:BRACKEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N 100 E STE 102
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7369
Mailing Address - Country:US
Mailing Address - Phone:435-986-2565
Mailing Address - Fax:
Practice Address - Street 1:25 N 100 E STE 102
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7369
Practice Address - Country:US
Practice Address - Phone:435-986-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6124913-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical