Basic Information
Provider Information | |||||||||
NPI: | 1487762514 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTH | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | MARIE CRAFFEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CRAFFEY | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AUD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 36007 | ||||||||
Address2: |   | ||||||||
City: | NORTH CHESTERFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 232358000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8044843700 | ||||||||
FaxNumber: | 8043206462 | ||||||||
Practice Location | |||||||||
Address1: | 3450 MAYLAND CT | ||||||||
Address2: |   | ||||||||
City: | HENRICO | ||||||||
State: | VA | ||||||||
PostalCode: | 232331468 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8044843700 | ||||||||
FaxNumber: | 8043206462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2006 | ||||||||
LastUpdateDate: | 11/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2201001318 | VA | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 010318254 | 05 | VA |   | MEDICAID |