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General NPI Number Information
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NPI Number | 1033666839
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Entity Type | Organization
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Legal Business Name | TABLE TALK
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Dates
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Enumeration Date | 09/09/2016
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Last Update Date | 09/09/2016
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Provider Practice Location Address
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Address Line | 47 S CRAWFORD ST
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City | DANVILLE
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State | IL
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Zip | 61832-6416
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Country | US
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Telephone | 770-990-6420
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Fax | 217-274-7202
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Provider Business Mailing Address
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Address Line | 47 S CRAWFORD ST
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City | DANVILLE
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State | IL
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Zip | 61832-6416
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Country | US
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Telephone | 770-990-6420
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Fax |
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Authorized Official
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Title or Position | CLINICAL COUNSELOR/PROPRIETOR
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Name | MRS. MARGIE LENE DASH
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Credential | M.S.
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Telephone | 770-990-6420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 180006014
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License Number State | IL
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