Provider Demographics
NPI:1710183504
Name:DR TARA F RAY PSYCHIATRIC SERVCIES, PLLC
Entity Type:Organization
Organization Name:DR TARA F RAY PSYCHIATRIC SERVCIES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:F
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-767-7960
Mailing Address - Street 1:PO BOX 9189
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-0189
Mailing Address - Country:US
Mailing Address - Phone:304-767-7960
Mailing Address - Fax:304-767-7969
Practice Address - Street 1:400 DIVISION ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1459
Practice Address - Country:US
Practice Address - Phone:304-767-7960
Practice Address - Fax:304-767-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002665Medicaid
WV=========OtherTAX ID