Provider Demographics
NPI:1639560378
Name:SMITH, TARA DEVI (PHD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DEVI
Last Name:SMITH
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 1:13855 HEDGEWOOD DRIVE
Mailing Address - Street 2:#245
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193
Mailing Address - Country:US
Mailing Address - Phone:703-490-0336
Mailing Address - Fax:
Practice Address - Street 1:13855 HEDGEWOOD DRIVE
Practice Address - Street 2:#245
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193
Practice Address - Country:US
Practice Address - Phone:703-490-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000948103T00000X
VA0810005135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist