Healthcare Provider Details

I. General information

NPI: 1790503084
Provider Name (Legal Business Name): AMANDA TALLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 W BEARDSLEY RD
GLENDALE AZ
85308-4711
US

IV. Provider business mailing address

7937 W SWEETWATER AVE
PEORIA AZ
85381-4013
US

V. Phone/Fax

Practice location:
  • Phone: 623-252-4357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-21948
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-21948
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: