Healthcare Provider Details

I. General information

NPI: 1740294107
Provider Name (Legal Business Name): JUDY E TALLEY M.A.,LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 GOLD AVE SW
ALBUQUERQUE NM
87102-2932
US

IV. Provider business mailing address

1001 GOLD AVE SW
ALBUQUERQUE NM
87102-2932
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-0776
  • Fax: 505-248-1582
Mailing address:
  • Phone: 505-842-0776
  • Fax: 505-248-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1454
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: