Provider Demographics
NPI:1770026825
Name:SOUTHALL, TARA (BCABA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SOUTHALL
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CROSS CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:VA
Mailing Address - Zip Code:24077-3038
Mailing Address - Country:US
Mailing Address - Phone:540-272-0462
Mailing Address - Fax:
Practice Address - Street 1:1314 RIVERLAND RD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-3610
Practice Address - Country:US
Practice Address - Phone:540-566-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000265106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst