Healthcare Provider Details

I. General information

NPI: 1124565080
Provider Name (Legal Business Name): TARA EADIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA CARGILL O.T.

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 FORT EUSTIS BLVD
YORKTOWN VA
23692-4163
US

IV. Provider business mailing address

16266 SMITHFIELD HEIGHTS DR
SMITHFIELD VA
23430-7056
US

V. Phone/Fax

Practice location:
  • Phone: 757-898-3746
  • Fax:
Mailing address:
  • Phone: 201-303-4118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119007149
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: