Provider Demographics
NPI:1710115142
Name:BOSWELL, TARA
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:BOSWELL
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 1:45 CALIFORNIA AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1618
Mailing Address - Country:US
Mailing Address - Phone:602-502-0161
Mailing Address - Fax:
Practice Address - Street 1:180 W HUFFAKER LN # 302-303
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-391-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0120106H00000X
NVPY0855103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist