Provider Demographics
NPI:1891358677
Name:TALLEY, MCKENNA (ACSW)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:TALLEY
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BERNAL RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1304
Mailing Address - Country:US
Mailing Address - Phone:408-361-0133
Mailing Address - Fax:
Practice Address - Street 1:150 BERNAL RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1304
Practice Address - Country:US
Practice Address - Phone:408-361-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW87866101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor