Healthcare Provider Details

I. General information

NPI: 1699103812
Provider Name (Legal Business Name): JAIME S TALLON SR. MH, PSYD, CMHP, CAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2013
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7490 SW 23RD ST SUITE NO, 201
MIAMI FL
33155-1419
US

IV. Provider business mailing address

7490 SW 23RD ST SUITE NO, 201
MIAMI FL
33155-1419
US

V. Phone/Fax

Practice location:
  • Phone: 786-953-8221
  • Fax: 305-485-3048
Mailing address:
  • Phone: 786-953-8221
  • Fax: 305-485-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7243
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number50541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: