Provider Demographics
NPI:1376135590
Name:TALLANT, SHANDA LYNN
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:LYNN
Last Name:TALLANT
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 1:615 ELSINORE PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1459
Mailing Address - Country:US
Mailing Address - Phone:833-510-4357
Mailing Address - Fax:866-460-2997
Practice Address - Street 1:2645 N LAUREL RD STE A
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-9075
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:866-460-2997
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175102101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)