Provider Demographics
NPI:1861922189
Name:RELATION, TARA (GN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:RELATION
Suffix:
Gender:F
Credentials:GN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 N STAR RD
Mailing Address - Street 2:
Mailing Address - City:MOOERS
Mailing Address - State:NY
Mailing Address - Zip Code:12958-3617
Mailing Address - Country:US
Mailing Address - Phone:518-534-1411
Mailing Address - Fax:
Practice Address - Street 1:574 N STAR RD
Practice Address - Street 2:
Practice Address - City:MOOERS
Practice Address - State:NY
Practice Address - Zip Code:12958-3617
Practice Address - Country:US
Practice Address - Phone:518-534-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP06458163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent