Healthcare Provider Details

I. General information

NPI: 1790221802
Provider Name (Legal Business Name): TA MARA'S PROMISE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 WEST AVE STE: 201
NEWPORT VA
23607
US

IV. Provider business mailing address

2601 WEST AVE STE: 201
NEWPORT VA
23607
US

V. Phone/Fax

Practice location:
  • Phone: 618-204-0190
  • Fax: 757-223-8100
Mailing address:
  • Phone: 618-204-0190
  • Fax: 757-223-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710102326
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number070105823
License Number StateVA

VIII. Authorized Official

Name: TAMARA PATRICE WILLIAMS
Title or Position: OWNER/CEO
Credential: LPC, MAC,CSAC
Phone: 757-748-4048