Provider Demographics
NPI:1508280207
Name:TAVKAR-CONLEY, POONAM (PHD)
Entity type:Individual
Prefix:DR
First Name:POONAM
Middle Name:
Last Name:TAVKAR-CONLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 LAKE GASTON DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-3932
Mailing Address - Country:US
Mailing Address - Phone:901-579-0766
Mailing Address - Fax:
Practice Address - Street 1:26001 REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-7762
Practice Address - Country:US
Practice Address - Phone:910-824-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-15
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical