Provider Demographics
NPI:1417670670
Name:ROSE, TARA JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:JEAN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:JEAN
Other - Last Name:HOVERSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:7 RICHLAND MEDICAL PARK DR STE 215
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6863
Practice Address - Country:US
Practice Address - Phone:803-434-3533
Practice Address - Fax:803-434-3904
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPSY1752103TC0700X
SC1752103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical