Provider Demographics
NPI:1114358306
Name:TEACHOUT, TARA JEAN
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:JEAN
Last Name:TEACHOUT
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 1:2550 E. FOOTHILL BLVD
Mailing Address - Street 2:PACIFIC CLINICS
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-463-1021
Mailing Address - Fax:626-578-0948
Practice Address - Street 1:2550 E. FOOTHILL BLVD
Practice Address - Street 2:PACIFIC CLINICS
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-463-1021
Practice Address - Fax:626-578-0948
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)