Basic Information
Provider Information | |||||||||
NPI: | 1902109044 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TALLY | ||||||||
FirstName: | MAARI | ||||||||
MiddleName: | ANGELA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORRIS | ||||||||
OtherFirstName: | MAARI | ||||||||
OtherMiddleName: | ANGELA | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1843 R.W. BERENDS DR. SW | ||||||||
Address2: |   | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 49519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6167732908 | ||||||||
FaxNumber: | 6165323046 | ||||||||
Practice Location | |||||||||
Address1: | 1843 R W BERENDS DR SW | ||||||||
Address2: |   | ||||||||
City: | WYOMING | ||||||||
State: | MI | ||||||||
PostalCode: | 495194955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6167732908 | ||||||||
FaxNumber: | 6165323046 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2010 | ||||||||
LastUpdateDate: | 05/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301015037 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TA0400X | 6301015037 | MI | N |   | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
No ID Information.