Healthcare Provider Details

I. General information

NPI: 1962851162
Provider Name (Legal Business Name): MRS. TARA CAULBOY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24275 JEFFERSON AVE
MURRIETA CA
92562-7285
US

IV. Provider business mailing address

24275 JEFFERSON AVE
MURRIETA CA
92562-7285
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-5599
  • Fax:
Mailing address:
  • Phone: 951-677-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number91788
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: