Provider Demographics
NPI:1902233737
Name:MOXHAM, TARA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MOXHAM
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 LUMBERJACK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6275
Mailing Address - Country:US
Mailing Address - Phone:321-952-1818
Mailing Address - Fax:
Practice Address - Street 1:4400 LUMBERJACK LN
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6275
Practice Address - Country:US
Practice Address - Phone:321-952-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist