Provider Demographics
NPI:1760907596
Name:TALLENT, DAWN ELIZABETH (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:ELIZABETH
Last Name:TALLENT
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MIMOSA LN
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-3012
Mailing Address - Country:US
Mailing Address - Phone:573-259-4970
Mailing Address - Fax:
Practice Address - Street 1:1132 ELMONT RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1039
Practice Address - Country:US
Practice Address - Phone:573-468-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOM465038917Medicaid