Provider Demographics
NPI:1245801760
Name:ELIA, TARA NICOLE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:ELIA
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 1:317 NIGHTINGALE SQ
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-5602
Mailing Address - Country:US
Mailing Address - Phone:732-614-5874
Mailing Address - Fax:
Practice Address - Street 1:101 E GATE DR
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2803
Practice Address - Country:US
Practice Address - Phone:856-810-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
106E00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst