Provider Demographics
NPI:1710264874
Name:DILL, TARA B C (PH D)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:B C
Last Name:DILL
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 JEFFERSON CT
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1118
Mailing Address - Country:US
Mailing Address - Phone:631-689-6717
Mailing Address - Fax:
Practice Address - Street 1:4 JEFFERSON CT
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1118
Practice Address - Country:US
Practice Address - Phone:631-689-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009945-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical