=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841154465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TALLACARE HEALTH AND WELLNESS SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2025
-----------------------------------------------------
Last Update Date | 12/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3205 LUCIA WAY
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75407-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-910-4090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3205 LUCIA WAY
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75407-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-910-4090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. CORANTIN TALLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-910-4090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 364SH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------