Provider Demographics
NPI:1619201514
Name:TALLEY, HEATHER NICHOLE (CCLS)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:NICHOLE
Last Name:TALLEY
Suffix:
Gender:F
Credentials:CCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MCDONALD DR
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-8079
Mailing Address - Country:US
Mailing Address - Phone:334-315-9230
Mailing Address - Fax:
Practice Address - Street 1:350 MCDONALD DR
Practice Address - Street 2:
Practice Address - City:WETUMPKA
Practice Address - State:AL
Practice Address - Zip Code:36092-8079
Practice Address - Country:US
Practice Address - Phone:334-315-9230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10262171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator