Provider Demographics
NPI:1518534296
Name:TALLEY, MELISSA D (DT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:TALLEY
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3339 STONEWAY CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2404
Mailing Address - Country:US
Mailing Address - Phone:121-789-8663
Mailing Address - Fax:
Practice Address - Street 1:3339 STONEWAY CT
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-2404
Practice Address - Country:US
Practice Address - Phone:121-789-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty