Provider Demographics
NPI:1376881151
Name:PACCILLO, TARA (MT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PACCILLO
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 RIVA AVE
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-2150
Mailing Address - Country:US
Mailing Address - Phone:732-422-6364
Mailing Address - Fax:732-422-6360
Practice Address - Street 1:196 RIVA AVE
Practice Address - Street 2:
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-2150
Practice Address - Country:US
Practice Address - Phone:732-422-6364
Practice Address - Fax:732-422-6360
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00273400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist