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General NPI Number Information
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NPI Number | 1710057104
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Entity Type | Individual
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Provider Name | TARA LEIGH KROG PHD
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Gender | Female
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 10/07/2011
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Provider Practice Location Address
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Address Line | 2916 E PIERCE
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City | PHOENIX
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State | AZ
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Zip | 85004
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Country | US
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Telephone | 602-344-5982
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Fax | 480-344-2114
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Provider Business Mailing Address
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Address Line | 2601 E. ROOSEVELT
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City | PHOENIX
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State | AZ
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Zip | 85004
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Country | US
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Telephone | 602-344-5982
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Fax | 480-344-2214
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 4025
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License Number State | AZ
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