Provider Demographics
NPI:1497526370
Name:THOMPSON, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:THOMPSON
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 1:139 HAZARD AVE.
Mailing Address - Street 2:BUILDING 2 SUITE 6
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082
Mailing Address - Country:US
Mailing Address - Phone:860-218-3614
Mailing Address - Fax:
Practice Address - Street 1:139 HAZARD AVE.
Practice Address - Street 2:BUILDING 2 SUITE 6
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-218-3614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician