Provider Demographics
NPI:1811472566
Name:REZZA, TARA ELISE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:ELISE
Last Name:REZZA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:BENCZKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1028 MAIN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1102
Mailing Address - Country:US
Mailing Address - Phone:716-859-5465
Mailing Address - Fax:716-859-5585
Practice Address - Street 1:1028 MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1102
Practice Address - Country:US
Practice Address - Phone:716-859-5465
Practice Address - Fax:716-859-5585
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NY026318103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor