Provider Demographics
NPI:1790817245
Name:TALLENT, MARC (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:TALLENT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY PL
Mailing Address - Street 2:APT 9M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4516
Mailing Address - Country:US
Mailing Address - Phone:212-645-5795
Mailing Address - Fax:
Practice Address - Street 1:51 5TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4320
Practice Address - Country:US
Practice Address - Phone:212-645-5795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008311-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01090711Medicaid
NYV27281Medicare ID - Type Unspecified