Provider Demographics
NPI:1407001555
Name:DEGUNYA, TARA L (MS ED, LMHC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:DEGUNYA
Suffix:
Gender:F
Credentials:MS ED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4839 BUELL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-3201
Mailing Address - Country:US
Mailing Address - Phone:260-341-6259
Mailing Address - Fax:
Practice Address - Street 1:4839 BUELL DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3201
Practice Address - Country:US
Practice Address - Phone:260-341-6259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002154A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health