Provider Demographics
NPI:1215429709
Name:KHADEM, TARA (LPC, CGP)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:KHADEM
Suffix:
Gender:F
Credentials:LPC, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 TIMBERLOCH PL STE 200
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1182
Mailing Address - Country:US
Mailing Address - Phone:346-351-4902
Mailing Address - Fax:
Practice Address - Street 1:2002 TIMBERLOCH PL STE 200
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:346-351-4902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional