Provider Demographics
NPI:1285455436
Name:TALLEY, AMANDA J
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
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 1:1607 DOWLING ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-9407
Mailing Address - Country:US
Mailing Address - Phone:260-347-5236
Mailing Address - Fax:
Practice Address - Street 1:3326 COUNTY ROAD 427
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IN
Practice Address - Zip Code:46793-9532
Practice Address - Country:US
Practice Address - Phone:260-920-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10233605103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool