Healthcare Provider Details

I. General information

NPI: 1912657016
Provider Name (Legal Business Name): LESLIE ETHAN TALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E MAIN ST
PICKENS SC
29671-2319
US

IV. Provider business mailing address

309 E MAIN ST
PICKENS SC
29671-2319
US

V. Phone/Fax

Practice location:
  • Phone: 864-898-5800
  • Fax:
Mailing address:
  • Phone: 864-898-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA21227
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: