Provider Demographics
NPI:1902977523
Name:BODEN, TARA LYNN (MS, LPCC NCC)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:LYNN
Last Name:BODEN
Suffix:
Gender:F
Credentials:MS, LPCC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 EL CENTRO FAMILIAR BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4502
Mailing Address - Country:US
Mailing Address - Phone:505-873-1604
Mailing Address - Fax:505-877-3533
Practice Address - Street 1:1710 EL CENTRO FAMILIAR BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4502
Practice Address - Country:US
Practice Address - Phone:505-873-1604
Practice Address - Fax:505-877-3533
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health