=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043174709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUE ELLEN TALLEY LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2025
-----------------------------------------------------
Last Update Date | 12/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28617 ACACIA GLEN ST
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-264-6931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28617 ACACIA GLEN ST
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-264-6931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MFC33811
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------