Provider Demographics
NPI:1215750898
Name:TALLEY, DAVELYN
Entity type:Individual
Prefix:
First Name:DAVELYN
Middle Name:
Last Name:TALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 NEWCASTLE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-1030
Mailing Address - Country:US
Mailing Address - Phone:704-492-5813
Mailing Address - Fax:
Practice Address - Street 1:1101 NEWCASTLE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-1030
Practice Address - Country:US
Practice Address - Phone:704-492-5813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29293101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)