Provider Demographics
NPI:1083166334
Name:HUMPHREY, TARA (BCBA, COBA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:BCBA, COBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 WAYNEGATE RD
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1157
Mailing Address - Country:US
Mailing Address - Phone:937-545-0140
Mailing Address - Fax:
Practice Address - Street 1:5929 WAYNEGATE RD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-1157
Practice Address - Country:US
Practice Address - Phone:937-545-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBACB#1-16-23725103K00000X
OHCOBA #286103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst