Provider Demographics
NPI:1134818636
Name:KIRBY, TARA (LMHC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KIRBY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 W HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1545
Mailing Address - Country:US
Mailing Address - Phone:850-380-4214
Mailing Address - Fax:
Practice Address - Street 1:320 E MIRACLE STRIP PKWY
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1926
Practice Address - Country:US
Practice Address - Phone:850-380-4214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health