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General NPI Number Information
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NPI Number | 1336912468
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Entity Type | Organization
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Legal Business Name | TABULA RASA INC
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Dates
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Enumeration Date | 10/31/2023
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Last Update Date | 12/19/2023
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Provider Practice Location Address
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Address Line | 27094 RIDGEVIEW SPRINGS RD
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City | HOT SPRINGS
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State | SD
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Zip | 57747-6033
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Country | US
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Telephone | 605-891-4377
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Fax |
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Provider Business Mailing Address
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Address Line | 27094 RIDGEVIEW SPRINGS RD
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City | HOT SPRINGS
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State | SD
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Zip | 57747-6033
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Country | US
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Telephone | 605-891-4377
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | MARTIN NEARY
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Credential |
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Telephone | 518-244-3737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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