=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417311424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY M TALLEY SR. LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2016
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8760 POWDERHORN WAY
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-1178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-590-4572
-----------------------------------------------------
Fax | 866-598-3720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8760 POWDERHORN WAY
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46256-1178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-590-4572
-----------------------------------------------------
Fax | 866-598-3720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 87001582A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 39002852A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------