Provider Demographics
NPI:1780005884
Name:TALACHY, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TALACHY
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 1:714 CALLE DON DIEGO
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3414
Mailing Address - Country:US
Mailing Address - Phone:505-753-2254
Mailing Address - Fax:
Practice Address - Street 1:714 CALLE DON DIEGO
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3414
Practice Address - Country:US
Practice Address - Phone:505-753-2254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-067431041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool