Healthcare Provider Details

I. General information

NPI: 1457266991
Provider Name (Legal Business Name): TARA MARIA ETHERIDGE PPSC, LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA MARIA BELLEZZA

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 GREY OAKS CT
OCEANSIDE CA
92056-6605
US

IV. Provider business mailing address

1428 GREY OAKS CT
OCEANSIDE CA
92056-6605
US

V. Phone/Fax

Practice location:
  • Phone: 760-695-9657
  • Fax:
Mailing address:
  • Phone: 760-695-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLEP4561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: