Healthcare Provider Details

I. General information

NPI: 1053835603
Provider Name (Legal Business Name): TARA ZOMBRES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA ZOMOUSE

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PAUL DR STE B
SAN RAFAEL CA
94903-2047
US

IV. Provider business mailing address

1663 MISSION ST STE 400
SAN FRANCISCO CA
94103-2485
US

V. Phone/Fax

Practice location:
  • Phone: 877-264-6747
  • Fax:
Mailing address:
  • Phone: 877-264-6747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: