Provider Demographics
NPI:1497905863
Name:BOADU, TARA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:M
Last Name:BOADU
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 S BERKELEY LAKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1660
Mailing Address - Country:US
Mailing Address - Phone:770-417-2724
Mailing Address - Fax:770-446-5643
Practice Address - Street 1:4530 S BERKELEY LAKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1660
Practice Address - Country:US
Practice Address - Phone:770-417-2724
Practice Address - Fax:770-446-5643
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical