Provider Demographics
NPI:1407277122
Name:MEHTA, TARA (PHD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 W ROOSEVELT RD
Mailing Address - Street 2:155 WORB
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1264
Mailing Address - Country:US
Mailing Address - Phone:312-996-3910
Mailing Address - Fax:
Practice Address - Street 1:1747 W ROOSEVELT RD
Practice Address - Street 2:155 WORB
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1264
Practice Address - Country:US
Practice Address - Phone:312-996-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008073103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical