Provider Demographics
NPI:1194109355
Name:MADINA, TALLACE (LPC, NCC)
Entity type:Individual
Prefix:MS
First Name:TALLACE
Middle Name:
Last Name:MADINA
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7262
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-7262
Mailing Address - Country:US
Mailing Address - Phone:504-906-5457
Mailing Address - Fax:
Practice Address - Street 1:3520 GENERAL DEGAULLE DR
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-6757
Practice Address - Country:US
Practice Address - Phone:504-906-5457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5548101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional