MEDICARE: MS. NANCY TALLEY MFT

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	106H00000X	Marriage & Family Therapist	MFT35109	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	499612	OTHER	CA	VALUE OPTIONS ID

General Provider Information

NPI Number	:	1780720417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NANCY TALLEY MFT

Provider Business Mailing Address
First Line	:	4405 W RIVERSIDE DR STE 208
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4050
Country	:	US
Telephone Number	:	818-842-3997
Fax Number	:	818-848-1380

Provider Business Practice Location Address
First Line	:	4405 W RIVERSIDE DR STE 208
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4050
Country	:	US
Telephone Number	:	818-842-3997
Fax Number	:	818-848-1380

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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