Provider Demographics
NPI:1548600943
Name:BOYLE, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BOYLE
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 1:6335 ANNIE OAKLEY DR
Mailing Address - Street 2:168
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3930
Mailing Address - Country:US
Mailing Address - Phone:702-468-6260
Mailing Address - Fax:
Practice Address - Street 1:3017 W CHARLESTON BLVD STE 70
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1928
Practice Address - Country:US
Practice Address - Phone:702-823-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TR0400X
NVMI4055106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1700046372Medicaid