Provider Demographics
NPI:1730129883
Name:TARACENA, BRIAN JONES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JONES
Last Name:TARACENA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-2716
Mailing Address - Country:US
Mailing Address - Phone:435-654-4037
Mailing Address - Fax:435-654-4077
Practice Address - Street 1:175 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1606
Practice Address - Country:US
Practice Address - Phone:435-654-4037
Practice Address - Fax:435-654-4077
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4923236-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000074055Medicare PIN