Healthcare Provider Details

I. General information

NPI: 1306166806
Provider Name (Legal Business Name): TARA PAPPAS-PHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA PAPPAS

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROAD ST
RICHMOND VA
23230-3958
US

IV. Provider business mailing address

3900 W BROAD ST
RICHMOND VA
23230-3958
US

V. Phone/Fax

Practice location:
  • Phone: 804-353-4461
  • Fax: 804-353-3061
Mailing address:
  • Phone: 804-353-4461
  • Fax: 804-353-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007313
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: