Provider Demographics
NPI:1578339420
Name:MCCOY, TAMARA DIONNE
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:DIONNE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:DIONNE
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMHC, NCC
Mailing Address - Street 1:511 TRAVERS CIR APT A
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3759
Mailing Address - Country:US
Mailing Address - Phone:269-861-9348
Mailing Address - Fax:
Practice Address - Street 1:813 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3102
Practice Address - Country:US
Practice Address - Phone:574-282-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004752A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health