Provider Demographics
NPI:1538301304
Name:BERKLEY, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BERKLEY
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 1:2461 W KIT CARSON TRL
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-1878
Mailing Address - Country:US
Mailing Address - Phone:602-326-2312
Mailing Address - Fax:
Practice Address - Street 1:2461 W KIT CARSON TRL
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-1878
Practice Address - Country:US
Practice Address - Phone:602-326-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1406917385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child