Provider Demographics
NPI:1235746793
Name:PATRICK, TARA ANN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:PATRICK
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 1:2451 LAKE RD APT 704
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-5733
Mailing Address - Country:US
Mailing Address - Phone:252-646-1808
Mailing Address - Fax:
Practice Address - Street 1:VETERANS AFFAIRS
Practice Address - Street 2:3850 RIDGEMONT
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606
Practice Address - Country:US
Practice Address - Phone:325-695-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69469104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker