Provider Demographics
NPI:1730376419
Name:KELLEY, TARA RUTH
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:RUTH
Last Name:KELLEY
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 1:2358 SILVERSIDES LOOP
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-1565
Mailing Address - Country:US
Mailing Address - Phone:850-791-6380
Mailing Address - Fax:
Practice Address - Street 1:2358 SILVERSIDES LOOP
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-1565
Practice Address - Country:US
Practice Address - Phone:850-791-6380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health