Organization
SHIRAZ TATA PHD LLC
Active
Other names
Shiraz P. Tata
Organization subpart
No
Provider details
NPI number
Authorized official
SHIRAZ P TATA PH D (LICENSED CLINICAL PSYCHOLOGIST)
(815) 519-2949
Entity
Organization
Contact information
Practice address
6072 BRYNWOOD DR STE 107, ROCKFORD, IL 61114
(815) 519-2949
Mailing address
6072 BRYNWOOD DR STE 107, ROCKFORD, IL 61114-5829
(815) 519-2949
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071.04963
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11740000
CAQH
—
01
—
819809569
BCBSIL
—
Enumeration date
06/27/2018
Last updated
08/01/2018
Update your record
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