Provider Demographics
NPI:1669109583
Name:TOBACK, TALIA (LISW-CP)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:TOBACK
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 APEX LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8639
Mailing Address - Country:US
Mailing Address - Phone:843-243-7026
Mailing Address - Fax:
Practice Address - Street 1:1276 APEX LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-8639
Practice Address - Country:US
Practice Address - Phone:843-243-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14505104100000X
SC167801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid