Provider Demographics
NPI:1346455169
Name:PRESTRIDGE, TARA LYNN THOMASSON (LPC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN THOMASSON
Last Name:PRESTRIDGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1846 N BEST FRIEND LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6520
Mailing Address - Country:US
Mailing Address - Phone:870-866-0681
Mailing Address - Fax:
Practice Address - Street 1:1846 N BEST FRIEND LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6520
Practice Address - Country:US
Practice Address - Phone:501-624-7111
Practice Address - Fax:501-620-5109
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0803025101Y00000X
ARP1110085101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid