Provider Demographics
NPI:1508280207
Name:TAVKAR-CONLEY, POONAM (PHD)
Entity Type:Individual
Prefix:MRS
First Name:POONAM
Middle Name:
Last Name:TAVKAR-CONLEY
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 1:1147 CULLY RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-8502
Mailing Address - Country:US
Mailing Address - Phone:901-624-6390
Mailing Address - Fax:901-624-0604
Practice Address - Street 1:1147 CULLY RD STE 102
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-8502
Practice Address - Country:US
Practice Address - Phone:901-624-6390
Practice Address - Fax:901-624-0604
Is Sole Proprietor?:No
Enumeration Date:2014-02-15
Last Update Date:2014-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical