Healthcare Provider Details

I. General information

NPI: 1275339301
Provider Name (Legal Business Name): TARA RAE DONER MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 N BROADWAY PH E
JERICHO NY
11753-2198
US

IV. Provider business mailing address

368 VETERANS MEMORIAL HWY STE 3
COMMACK NY
11725-4322
US

V. Phone/Fax

Practice location:
  • Phone: 631-533-0315
  • Fax: 855-752-5170
Mailing address:
  • Phone: 631-533-0315
  • Fax: 855-752-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP133460
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: