Provider Demographics
NPI:1083490098
Name:MACDONALD, TARA ANN (MENTAL HEALTH INTERN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MENTAL HEALTH INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 SE CROSSPOINT DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2624
Mailing Address - Country:US
Mailing Address - Phone:772-333-7370
Mailing Address - Fax:
Practice Address - Street 1:160 NW CENTRAL PARK PLZ STE 104
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1825
Practice Address - Country:US
Practice Address - Phone:772-303-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH24059101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health