Provider Demographics
NPI:1790221802
Name:TA MARA'S PROMISE, LLC
Entity Type:Organization
Organization Name:TA MARA'S PROMISE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, MAC,CSAC
Authorized Official - Phone:757-748-4048
Mailing Address - Street 1:2601 WEST AVE
Mailing Address - Street 2:STE: 201
Mailing Address - City:NEWPORT
Mailing Address - State:VA
Mailing Address - Zip Code:23607
Mailing Address - Country:US
Mailing Address - Phone:618-204-0190
Mailing Address - Fax:757-223-8100
Practice Address - Street 1:2601 WEST AVE
Practice Address - Street 2:STE: 201
Practice Address - City:NEWPORT
Practice Address - State:VA
Practice Address - Zip Code:23607
Practice Address - Country:US
Practice Address - Phone:618-204-0190
Practice Address - Fax:757-223-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102326101YA0400X
VA070105823101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty