Provider Demographics
NPI:1760960744
Name:PORT, TAMARA K
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:K
Last Name:PORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:K
Other - Last Name:IMFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42 W COLONIAL HWY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:VA
Mailing Address - Zip Code:20158-9007
Mailing Address - Country:US
Mailing Address - Phone:540-208-5628
Mailing Address - Fax:800-735-4520
Practice Address - Street 1:42 W COLONIAL HWY
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:VA
Practice Address - Zip Code:20158-9007
Practice Address - Country:US
Practice Address - Phone:540-208-5628
Practice Address - Fax:800-735-4520
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040087021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty