Individual
AUTUMN TALLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
9114 37TH AVE, JACKSON HEIGHTS, NY 11372-7920
(718) 779-1600
(347) 612-4162
Mailing address
9114 37TH AVE, JACKSON HEIGHTS, NY 11372-7920
(718) 779-1600
(347) 612-4162
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
T02960696961931
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
T02960696961931
—
NJ
Enumeration date
10/10/2018
Last updated
10/10/2018
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