Provider Demographics
NPI:1356499842
Name:TALLMAN, SAM (LCSW)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:TALLMAN
Suffix:
Gender:M
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:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:MANZANITA
Mailing Address - State:OR
Mailing Address - Zip Code:97130-0178
Mailing Address - Country:US
Mailing Address - Phone:150-336-8686
Mailing Address - Fax:150-336-8497
Practice Address - Street 1:855 3RD STREET
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:OR
Practice Address - Zip Code:97147-9999
Practice Address - Country:US
Practice Address - Phone:150-336-8686
Practice Address - Fax:150-336-8497
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR08591Medicare UPIN
ORR0000TLFBRMedicare ID - Type Unspecified