Provider Demographics
NPI:1063267110
Name:STEWART, TARA (PHD, CNIM, DABNM)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:PHD, CNIM, DABNM
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:KIRKPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 WOODMERE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-4751
Mailing Address - Country:US
Mailing Address - Phone:916-631-0112
Mailing Address - Fax:
Practice Address - Street 1:111 WOODMERE RD STE 150
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4751
Practice Address - Country:US
Practice Address - Phone:916-631-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist