Healthcare Provider Details

I. General information

NPI: 1891360509
Provider Name (Legal Business Name): SAVANNA ELAINE TALLY CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8261 MARKET ST
BOARDMAN OH
44512-6254
US

IV. Provider business mailing address

8261 MARKET ST
BOARDMAN OH
44512-6254
US

V. Phone/Fax

Practice location:
  • Phone: 330-286-0050
  • Fax:
Mailing address:
  • Phone: 330-286-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.176875
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: