Provider Demographics
NPI:1164714986
Name:VIRGIL, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:VIRGIL
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 1:400 SUNRISE HWY
Mailing Address - Street 2:CARONE HALL 1ST FLOOR
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2508
Mailing Address - Country:US
Mailing Address - Phone:631-608-5028
Mailing Address - Fax:631-264-4509
Practice Address - Street 1:400 SUNRISE HWY
Practice Address - Street 2:CARONE HALL 1ST FLOOR
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2508
Practice Address - Country:US
Practice Address - Phone:631-608-5028
Practice Address - Fax:631-264-4509
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health