Basic Information
| Provider Information | |||||||||
| NPI: | 1508332768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TALLMAN | ||||||||
| FirstName: | SHENNANDOAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 LIVE OAK RD | ||||||||
| Address2: | |||||||||
| City: | CASTLE ROCK | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801048548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646082367 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6197 LEHMAN DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192661000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2018 | ||||||||
| LastUpdateDate: | 03/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-20-41609 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.