Provider Demographics
NPI:1902535982
Name:ERNST, TARA L (LAC)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:L
Last Name:ERNST
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S MONTEZUMA ST STE 205206
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4712
Mailing Address - Country:US
Mailing Address - Phone:928-756-0906
Mailing Address - Fax:
Practice Address - Street 1:23107 E VIA DEL SOL
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-1275
Practice Address - Country:US
Practice Address - Phone:480-600-6838
Practice Address - Fax:833-623-4430
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1710412382OtherNPI OF CLINICAL SUPERVISOR (MARIE TUELLER, MED, LPC)