Healthcare Provider Details

I. General information

NPI: 1588681472
Provider Name (Legal Business Name): TARA V SPEVACK PH.D., ABPP-CN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL #3S32
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PL #3S32
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6069
  • Fax: 314-454-4576
Mailing address:
  • Phone: 314-454-6069
  • Fax: 314-454-4576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1999135246
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: