Provider Demographics
NPI:1437691862
Name:TALLY, MONA C (LSW)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:C
Last Name:TALLY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 FERNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-4319
Mailing Address - Country:US
Mailing Address - Phone:609-816-5199
Mailing Address - Fax:
Practice Address - Street 1:619 FERNWOOD AVE
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-4319
Practice Address - Country:US
Practice Address - Phone:609-816-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05947600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker