Provider Demographics
NPI:1538702881
Name:MISKOVICH, TARA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:ANN
Last Name:MISKOVICH
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 1:5342 DUDLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MCCLELLAN
Mailing Address - State:CA
Mailing Address - Zip Code:95652-1012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5342 DUDLEY BLVD
Practice Address - Street 2:
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1012
Practice Address - Country:US
Practice Address - Phone:916-561-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical