Provider Demographics
NPI:1073194528
Name:BERNARD, TARA TINIQUE
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:TINIQUE
Last Name:BERNARD
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 1:1105 N STONEMAN AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1079
Mailing Address - Country:US
Mailing Address - Phone:626-394-9299
Mailing Address - Fax:
Practice Address - Street 1:1105 N STONEMAN AVE APT B
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1079
Practice Address - Country:US
Practice Address - Phone:626-538-5048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23016235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist