=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679937627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THELESE CONSULTING GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2016
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8929 S. SEPULVEDA BLVD SUITE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-317-6800
-----------------------------------------------------
Fax | 877-219-8239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8929 S. SEPULVEDA BLVD SUITE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-317-6800
-----------------------------------------------------
Fax | 877-219-8239
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | DR. WENDY THELESE TALLEY
-----------------------------------------------------
Credential | DSW, LCSW
-----------------------------------------------------
Telephone | 424-317-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 25988
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------