Basic Information
| Provider Information | |||||||||
| NPI: | 1447733951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TALLY | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | LAMONT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1041 HOVEY ST SW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495046154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139805533 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2018 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.