| Shiraz Tata Phd Llc | |
|
6072 Brynwood Dr Ste 107 Rockford IL 61114 | |
| (815) 519-2949 | |
| Not Available |
| Full Name | Shiraz Tata Phd Llc |
|---|---|
| Speciality | Psychologist |
| Location | 6072 Brynwood Dr Ste 107, Rockford, Illinois |
| Authorized Official Name and Position | Shiraz P Tata (LICENSED CLINICAL PSYCHOLOGIST) |
| Authorized Official Contact | 8155192949 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Shiraz Tata Phd Llc 6072 Brynwood Dr Ste 107 Rockford IL 61114-5829 Ph: (815) 519-2949 | Shiraz Tata Phd Llc 6072 Brynwood Dr Ste 107 Rockford IL 61114 Ph: (815) 519-2949 |
| NPI Number | 1083109524 |
|---|---|
| Provider Enumeration Date | 06/27/2018 |
| Last Update Date | 08/01/2018 |
| Medicare PECOS PAC ID | 2668718198 |
|---|---|
| Medicare Enrollment ID | O20190103003194 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1083109524 | NPI | - | NPPES |
| 819809569 | Other | BCBSIL | |
| 11740000 | Other | CAQH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 071.04963 (Illinois) | Primary |
| Provider Name | Shiraz P Tata |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1336298504 PECOS PAC ID: 4385980812 Enrollment ID: I20190103003268 |
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