Healthcare Provider Details

I. General information

NPI: 1174450001
Provider Name (Legal Business Name): TARA BOUCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 9TH ST FRNT
SANTA MONICA CA
90403-2845
US

IV. Provider business mailing address

927 9TH ST FRNT
SANTA MONICA CA
90403-2845
US

V. Phone/Fax

Practice location:
  • Phone: 310-804-6627
  • Fax:
Mailing address:
  • Phone: 310-804-6627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: