Provider Demographics
NPI:1982603692
Name:BROWN, TARA WALL (PSYD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:WALL
Last Name:BROWN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:8500 EXECUTIVE PARK AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2225
Mailing Address - Country:US
Mailing Address - Phone:703-698-5200
Mailing Address - Fax:703-573-2351
Practice Address - Street 1:8500 EXECUTIVE PARK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2225
Practice Address - Country:US
Practice Address - Phone:703-698-5200
Practice Address - Fax:703-573-2351
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003400103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139478OtherANTHEM
VA681761OtherNCPPO
VA735839-000OtherMAGELLAN
VA0081OtherCAREFIRST DC
7513603OtherAETNA
2160264OtherMAMSI