Provider Demographics
NPI:1699918862
Name:ISKOVITZ, TALLY (LPC)
Entity type:Individual
Prefix:
First Name:TALLY
Middle Name:
Last Name:ISKOVITZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 S STAPLEY DR
Mailing Address - Street 2:ANASAZI FOUNDATION
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5877
Mailing Address - Country:US
Mailing Address - Phone:480-982-2356
Mailing Address - Fax:
Practice Address - Street 1:1424 S STAPLEY DR
Practice Address - Street 2:ANASAZI FOUNDATION - SAN TAN COUNSELING
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5877
Practice Address - Country:US
Practice Address - Phone:480-982-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13677101YP2500X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor