Provider Demographics
NPI:1124568241
Name:COTHREN, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:COTHREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 OID FOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501
Mailing Address - Country:US
Mailing Address - Phone:434-455-5342
Mailing Address - Fax:434-485-8877
Practice Address - Street 1:37 VILLAGE HWY
Practice Address - Street 2:
Practice Address - City:RUSTBURG
Practice Address - State:VA
Practice Address - Zip Code:24588-4112
Practice Address - Country:US
Practice Address - Phone:434-332-5149
Practice Address - Fax:434-485-8877
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006934101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional