Provider Demographics
NPI:1114316395
Name:TARA M. BOADU, PSY.D. LLC
Entity Type:Organization
Organization Name:TARA M. BOADU, PSY.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOADU
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-643-4495
Mailing Address - Street 1:4530 S BERKELEY LAKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BERKELEY LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1660
Mailing Address - Country:US
Mailing Address - Phone:470-514-3727
Mailing Address - Fax:770-446-5643
Practice Address - Street 1:4530 S BERKELEY LAKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:BERKELEY LAKE
Practice Address - State:GA
Practice Address - Zip Code:30071-1660
Practice Address - Country:US
Practice Address - Phone:470-514-3727
Practice Address - Fax:770-446-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty