Provider Demographics
NPI:1134763071
Name:BODDIE, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BODDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 ARDEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-8448
Mailing Address - Country:US
Mailing Address - Phone:404-429-3747
Mailing Address - Fax:
Practice Address - Street 1:2038 ARDEN OAKS DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-8448
Practice Address - Country:US
Practice Address - Phone:404-429-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18660101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty