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General NPI Number Information
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NPI Number | 1124565080
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Entity Type | Individual
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Provider Name | TARA EADIE
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Gender | Female
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Dates
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Enumeration Date | 01/30/2017
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Last Update Date | 01/30/2017
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Provider Practice Location Address
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Address Line | 2405 FORT EUSTIS BLVD
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City | YORKTOWN
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State | VA
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Zip | 23692-4163
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Country | US
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Telephone | 757-898-3746
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Fax |
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Provider Business Mailing Address
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Address Line | 16266 SMITHFIELD HEIGHTS DR
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City | SMITHFIELD
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State | VA
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Zip | 23430-7056
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Country | US
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Telephone | 201-303-4118
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 0119007149
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License Number State | VA
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