Healthcare Provider Details

I. General information

NPI: 1356647200
Provider Name (Legal Business Name): TARA L CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST SUITE B
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

769 W BLAINE ST SUITE B
RIVERSIDE CA
92507-3970
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4705
  • Fax: 951-358-4719
Mailing address:
  • Phone: 951-358-4705
  • Fax: 951-358-4719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF 64859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: