Provider Demographics
NPI:1285718643
Name:TALLANT, LISA WELCH (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:WELCH
Last Name:TALLANT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 WELLSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3421
Mailing Address - Country:US
Mailing Address - Phone:678-587-0641
Mailing Address - Fax:678-587-0641
Practice Address - Street 1:1532 DUNWOODY VILLAGE PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4136
Practice Address - Country:US
Practice Address - Phone:404-578-6543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00968272AMedicaid