Basic Information
| Provider Information | |||||||||
| NPI: | 1659773760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | TARA | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10175 FORTUNE PARKWAY | ||||||||
| Address2: | SUITE 903 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045380713 | ||||||||
| FaxNumber: | 9045380714 | ||||||||
| Practice Location | |||||||||
| Address1: | 11512 LAKE MEAD AVE. | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043748536 | ||||||||
| FaxNumber: | 9045380714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2014 | ||||||||
| LastUpdateDate: | 09/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.