Provider Demographics
NPI:1710576731
Name:POULIN, TALITHA
Entity Type:Individual
Prefix:
First Name:TALITHA
Middle Name:
Last Name:POULIN
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 1:417 E GERMAN ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1028
Mailing Address - Country:US
Mailing Address - Phone:315-868-1000
Mailing Address - Fax:
Practice Address - Street 1:417 E GERMAN ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1028
Practice Address - Country:US
Practice Address - Phone:315-868-1000
Practice Address - Fax:315-866-3174
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094466104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker