Basic Information
Provider Information | |||||||||
NPI: | 1124568241 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COTHREN | ||||||||
FirstName: | TARA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3410 OID FOREST ROAD | ||||||||
Address2: |   | ||||||||
City: | LYNCHBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 24501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4344555342 | ||||||||
FaxNumber: | 4344858877 | ||||||||
Practice Location | |||||||||
Address1: | 37 VILLAGE HWY | ||||||||
Address2: |   | ||||||||
City: | RUSTBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 245884112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4343325149 | ||||||||
FaxNumber: | 4344858877 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2017 | ||||||||
LastUpdateDate: | 03/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701006934 | VA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.