Provider Demographics
NPI:1013691690
Name:PROSS, TARA (TRICHOLOGIST)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PROSS
Suffix:
Gender:F
Credentials:TRICHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 LATTINTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12542-5158
Mailing Address - Country:US
Mailing Address - Phone:845-863-9977
Mailing Address - Fax:
Practice Address - Street 1:10 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NY
Practice Address - Zip Code:12542-6164
Practice Address - Country:US
Practice Address - Phone:845-863-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAJ12DYPTNY335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier