Provider Demographics
NPI:1659145225
Name:RODRIGUEZ, TARA LYN (MS, LAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 S ALMA SCHOOL RD STE 11
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4036
Mailing Address - Country:US
Mailing Address - Phone:602-730-2622
Mailing Address - Fax:
Practice Address - Street 1:2950 S ALMA SCHOOL RD STE 11
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4036
Practice Address - Country:US
Practice Address - Phone:602-730-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-19366101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health