Healthcare Provider Details

I. General information

NPI: 1225574031
Provider Name (Legal Business Name): JEREMY RYAN TALLMAN LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9030 ROUTE 108 SUITE A
COLUMBIA MD
21045-1990
US

IV. Provider business mailing address

9030 ROUTE 108 SUITE A
COLUMBIA MD
21045-1990
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-1901
  • Fax: 410-740-2503
Mailing address:
  • Phone: 410-740-1901
  • Fax: 410-740-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC7560
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: