Individual
TARA BANKS WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSY.D.
Contact information
Practice address
8626 LEE HWY STE 200, FAIRFAX, VA 22031-2135
(571) 393-0075
Mailing address
12043 ELLIOTS OAK PL, BRISTOW, VA 20136-1265
Taxonomy
Speciality
Code
Description
License number
State
103TC2200X
Clinical Child & Adolescent Psychologist
Primary
0810004361
VA
Other
Enumeration date
05/23/2011
Last updated
05/23/2011
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