Basic Information
| Provider Information | |||||||||
| NPI: | 1477814911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOERNER | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUSSIN | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT 45305 | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19720 VENTURA BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913642676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182618286 | ||||||||
| FaxNumber: | 8189638727 | ||||||||
| Practice Location | |||||||||
| Address1: | 19720 VENTURA BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182618286 | ||||||||
| FaxNumber: | 8189638727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2012 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT45305 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.