Healthcare Provider Details

I. General information

NPI: 1730043761
Provider Name (Legal Business Name): DANIEL TALLEY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAKE ST STE 216
OAK PARK IL
60301-1147
US

IV. Provider business mailing address

1412 GUNDERSON AVE
BERWYN IL
60402-1153
US

V. Phone/Fax

Practice location:
  • Phone: 901-462-1806
  • Fax:
Mailing address:
  • Phone: 901-462-1806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL TALLEY
Title or Position: THERAPIST
Credential: LCSW
Phone: 901-462-1806