Provider Demographics
NPI:1023319795
Name:SUDSIRI, TARA MARLENE (LMHC)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:MARLENE
Last Name:SUDSIRI
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:MARLENE
Other - Last Name:MCNAIRE-GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:3648 SICKLE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-3833
Mailing Address - Country:US
Mailing Address - Phone:407-234-7408
Mailing Address - Fax:
Practice Address - Street 1:3648 SICKLE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-3833
Practice Address - Country:US
Practice Address - Phone:407-234-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7339101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health