Basic Information
| Provider Information | |||||||||
| NPI: | 1255793345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARRY | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | MAYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 DAVIS BLVD | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132502506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 DAVIS BLVD | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132598510 | ||||||||
| FaxNumber: | 8132598660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2016 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.