Provider Demographics
NPI:1487170585
Name:SMITH, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SMITH
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 1:4316 28TH PLACE
Mailing Address - Street 2:APT. 1
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712
Mailing Address - Country:US
Mailing Address - Phone:202-400-9666
Mailing Address - Fax:
Practice Address - Street 1:4316 28TH PL APT 1
Practice Address - Street 2:
Practice Address - City:MOUNT RAINIER
Practice Address - State:MD
Practice Address - Zip Code:20712-1533
Practice Address - Country:US
Practice Address - Phone:202-400-9666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician