Provider Demographics
NPI:1619720604
Name:BENDER, TARA ELAINE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ELAINE
Last Name:BENDER
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 1:9465 FARNHAM ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1308
Mailing Address - Country:US
Mailing Address - Phone:858-573-2600
Mailing Address - Fax:
Practice Address - Street 1:474 W VERMONT AVE STE 104
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-6584
Practice Address - Country:US
Practice Address - Phone:760-432-9884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-JYPNEI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist