Provider Demographics
NPI:1043789209
Name:NULL, TARA JILL (LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JILL
Last Name:NULL
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 FALLS DR NW
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-8093
Mailing Address - Country:US
Mailing Address - Phone:276-258-5921
Mailing Address - Fax:
Practice Address - Street 1:353 FALLS DR NW
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-8093
Practice Address - Country:US
Practice Address - Phone:276-258-5921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-17
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103240101YA0400X
VA0701010215101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)