Healthcare Provider Details

I. General information

NPI: 1619009743
Provider Name (Legal Business Name): TARA MARQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 F ST
MODESTO CA
95354-2451
US

IV. Provider business mailing address

840 SAPPHIRE CT
MANTECA CA
95336-3353
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-5879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberIMF48832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: