Provider Demographics
NPI:1679266076
Name:TALLEY, TYREE DEANA (CSAC-S, QMHP A/C)
Entity Type:Individual
Prefix:
First Name:TYREE
Middle Name:DEANA
Last Name:TALLEY
Suffix:
Gender:F
Credentials:CSAC-S, QMHP A/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23075-1429
Mailing Address - Country:US
Mailing Address - Phone:804-503-8454
Mailing Address - Fax:
Practice Address - Street 1:4860 COX RD # 244
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-9275
Practice Address - Country:US
Practice Address - Phone:804-503-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0732008364101Y00000X
VA0709024432101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor