Provider Demographics
NPI:1083109524
Name:SHIRAZ TATA PHD LLC
Entity Type:Organization
Organization Name:SHIRAZ TATA PHD LLC
Other - Org Name:SHIRAZ P. TATA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHIRAZ
Authorized Official - Middle Name:P
Authorized Official - Last Name:TATA
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:815-519-2949
Mailing Address - Street 1:6072 BRYNWOOD DR STE 107
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5829
Mailing Address - Country:US
Mailing Address - Phone:815-519-2949
Mailing Address - Fax:
Practice Address - Street 1:6072 BRYNWOOD DR STE 107
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114
Practice Address - Country:US
Practice Address - Phone:815-519-2949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.04963103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
819809569OtherBCBSIL
11740000OtherCAQH