MEDICARE: MRS. WENDY THELESE TALLEY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	25988	CA
2	1041C0700X	Clinical Social Worker	25988	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1679937627	OTHER	CA	GROUP NPI

General Provider Information

NPI Number	:	1013108521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WENDY THELESE TALLEY LCSW

Provider Business Mailing Address
First Line	:	8929 S SEPULVEDA BLVD STE 410
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3634
Country	:	US
Telephone Number	:	424-317-6800
Fax Number	:	877-219-8239

Provider Business Practice Location Address
First Line	:	8929 S SEPULVEDA BLVD STE 410
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3634
Country	:	US
Telephone Number	:	424-317-6800
Fax Number	:	877-219-8239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	04/22/2019

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