Provider Demographics
NPI:1073968061
Name:TARA ACEVEDO, PSY.D., PC
Entity Type:Organization
Organization Name:TARA ACEVEDO, PSY.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:610-217-0821
Mailing Address - Street 1:6213 DEEP EARTH LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2565
Mailing Address - Country:US
Mailing Address - Phone:610-217-0821
Mailing Address - Fax:
Practice Address - Street 1:6213 DEEP EARTH LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2565
Practice Address - Country:US
Practice Address - Phone:610-217-0821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05587103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty