Provider Demographics
NPI:1174674501
Name:THOMPSON, TARA G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:G
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:KATHLEEN
Other - Last Name:GIDNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2591 SE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-7504
Mailing Address - Country:US
Mailing Address - Phone:773-879-8272
Mailing Address - Fax:
Practice Address - Street 1:1881 N UNIVERSITY DR
Practice Address - Street 2:STE 104
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-8915
Practice Address - Country:US
Practice Address - Phone:954-340-0888
Practice Address - Fax:954-346-0909
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71007131103TC0700X
FLPY8628103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical