Provider Demographics
NPI:1114088184
Name:TANAKA, TARA RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:TANAKA
Suffix:
Gender:F
Credentials:PHD
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 2237
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95696-8237
Mailing Address - Country:US
Mailing Address - Phone:707-430-1165
Mailing Address - Fax:
Practice Address - Street 1:1600 CALIFORNIA DRIVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95696
Practice Address - Country:US
Practice Address - Phone:707-430-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21641103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical