Provider Demographics
NPI:1023162880
Name:MORGAN, TAVIA
Entity type:Individual
Prefix:
First Name:TAVIA
Middle Name:
Last Name:MORGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FERNANDE
Other - Middle Name:TAVIA
Other - Last Name:MORGAN-PACHUTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1311 S MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5457
Mailing Address - Country:US
Mailing Address - Phone:301-829-2242
Mailing Address - Fax:
Practice Address - Street 1:1311 S MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5457
Practice Address - Country:US
Practice Address - Phone:301-829-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB31411390200000X
MD05833103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770288900OtherTAX ID