Healthcare Provider Details

I. General information

NPI: 1396246393
Provider Name (Legal Business Name): TARA EDDY M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15260 VENTURA BLVD FL 12
SHERMAN OAKS CA
91403-5334
US

IV. Provider business mailing address

15234 LA MAIDA ST
SHERMAN OAKS CA
91403-1920
US

V. Phone/Fax

Practice location:
  • Phone: 203-921-7037
  • Fax:
Mailing address:
  • Phone: 203-921-7037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3685
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: