MEDICARE: TARA SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-19031	AZ

General Provider Information

NPI Number	:	1780208777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA SMITH

Provider Business Mailing Address
First Line	:	1815 W COLTER ST APT 27
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-3044
Country	:	US
Telephone Number	:	520-730-5585
Fax Number	:

Provider Business Practice Location Address
First Line	:	5060 N 19TH AVE # 207-7
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-3210
Country	:	US
Telephone Number	:	520-730-5585
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2020
Last Update Date	:	08/02/2021

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Directions to “ TARA SMITH ” Practice Location

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