Provider Demographics
NPI:1043385081
Name:BOGS, TARA MABEL BRANNON (PHD)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MABEL BRANNON
Last Name:BOGS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-2700
Mailing Address - Country:US
Mailing Address - Phone:401-369-9224
Mailing Address - Fax:401-369-9275
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:SUITE 517
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1617
Practice Address - Country:US
Practice Address - Phone:401-732-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25755103TC0700X
101YM0800X
RIPS01420103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health