Provider Demographics
NPI:1346315447
Name:BOOTH, TARA C (PSY D)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 MORENA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3703
Mailing Address - Country:US
Mailing Address - Phone:619-275-8000
Mailing Address - Fax:619-275-8005
Practice Address - Street 1:1675 MORENA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3703
Practice Address - Country:US
Practice Address - Phone:619-275-8000
Practice Address - Fax:619-275-8005
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19590103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1512013461Medicaid
CA1512013461Medicare ID - Type Unspecified
CA1512013461Medicaid