Healthcare Provider Details

I. General information

NPI: 1710470489
Provider Name (Legal Business Name): TARA O'SULLIVAN DYE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 APACHE AVE
SANTA FE NM
87505
US

IV. Provider business mailing address

1316 APACHE AVE
SANTA FE NM
87505-3212
US

V. Phone/Fax

Practice location:
  • Phone: 310-721-4398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number75454
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCBT-2022-0761
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: