Healthcare Provider Details

I. General information

NPI: 1043385081
Provider Name (Legal Business Name): TARA MABEL BRANNON BOGS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BALD HILL RD SUITE 517
WARWICK RI
02886-1617
US

IV. Provider business mailing address

1075 SMITH ST
PROVIDENCE RI
02908-2700
US

V. Phone/Fax

Practice location:
  • Phone: 401-732-1500
  • Fax:
Mailing address:
  • Phone: 401-369-9224
  • Fax: 401-369-9275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY25755
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01420
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: