Provider Demographics
NPI:1619478575
Name:TALLENT, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TALLENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 S GILBERT RD STE 101-103
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-2268
Mailing Address - Country:US
Mailing Address - Phone:480-482-5005
Mailing Address - Fax:480-376-2311
Practice Address - Street 1:538 S GILBERT RD STE 101-103
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2268
Practice Address - Country:US
Practice Address - Phone:480-482-5005
Practice Address - Fax:480-376-2311
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician