Provider Demographics
NPI:1861990871
Name:PETERSON, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88241-0907
Mailing Address - Country:US
Mailing Address - Phone:575-393-3168
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:3821 W COLLEGE LN
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88242-9126
Practice Address - Country:US
Practice Address - Phone:575-393-3168
Practice Address - Fax:575-397-4659
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11654841-2506103K00000X
NM1-18-33393103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst