MEDICARE: DR. TARA MCKELVY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1114471927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA MCKELVY PHD

Provider Business Mailing Address
First Line	:	1650 W ROSEDALE ST
Second Line	:	STE 305
City	:	FT WORTH
State	:	TX
Zip	:	76104-7400
Country	:	US
Telephone Number	:	682-841-1475
Fax Number	:

Provider Business Practice Location Address
First Line	:	12801 N CENTRAL EXPY
Second Line	:	1730
City	:	DALLAS
State	:	TX
Zip	:	75243-1716
Country	:	US
Telephone Number	:	469-751-8560
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2016
Last Update Date	:	07/27/2022

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