Provider Demographics
NPI:1447935663
Name:TALBERT, MISHAN
Entity type:Individual
Prefix:
First Name:MISHAN
Middle Name:
Last Name:TALBERT
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 1:814 W SOUTH ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:IL
Mailing Address - Zip Code:60545-1785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:814 W SOUTH ST APT 2D
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545-1785
Practice Address - Country:US
Practice Address - Phone:630-301-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227014154225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist