Healthcare Provider Details

I. General information

NPI: 1154626851
Provider Name (Legal Business Name): TARA MARIE AQUINO MS CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 ST JOHNS PARKSIDE
BUFFALO NY
14210-2515
US

IV. Provider business mailing address

61 MCKINLEY AVE APT A
WILLIAMSVILLE NY
14221-7134
US

V. Phone/Fax

Practice location:
  • Phone: 716-828-9560
  • Fax: 716-828-9460
Mailing address:
  • Phone: 716-353-1194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number433781101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: