Provider Demographics
NPI:1487762514
Name:RUTH, TARA MARIE CRAFFEY (AUD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE CRAFFEY
Last Name:RUTH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:CRAFFEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:PO BOX 36007
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-8000
Mailing Address - Country:US
Mailing Address - Phone:804-484-3700
Mailing Address - Fax:804-320-6462
Practice Address - Street 1:3450 MAYLAND CT
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1468
Practice Address - Country:US
Practice Address - Phone:804-484-3700
Practice Address - Fax:804-320-6462
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001318231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010318254Medicaid