Healthcare Provider Details

I. General information

NPI: 1821950742
Provider Name (Legal Business Name): ELIZABETH TALLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 11/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 ASH ST
LEAWOOD KS
66211-1925
US

IV. Provider business mailing address

2825 W 176TH ST
OVERLAND PARK KS
66085-8542
US

V. Phone/Fax

Practice location:
  • Phone: 231-288-7371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number03811
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: