Provider Demographics
NPI:1811208432
Name:TALBOT, COREEN MARIE (MA, LAC)
Entity Type:Individual
Prefix:
First Name:COREEN
Middle Name:MARIE
Last Name:TALBOT
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 N 16TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5375
Mailing Address - Country:US
Mailing Address - Phone:602-248-9247
Mailing Address - Fax:602-248-8936
Practice Address - Street 1:4201 N 16TH ST STE 250
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5375
Practice Address - Country:US
Practice Address - Phone:602-248-9247
Practice Address - Fax:602-248-8936
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-13450101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health