Provider Demographics
NPI:1740803543
Name:BOLAND, TARA SHAWN (BEHAVIOR ANALYST)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:SHAWN
Last Name:BOLAND
Suffix:
Gender:F
Credentials:BEHAVIOR ANALYST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31350 RANCHO VISTA RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6200
Mailing Address - Country:US
Mailing Address - Phone:951-595-9563
Mailing Address - Fax:
Practice Address - Street 1:31350 RANCHO VISTA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-6200
Practice Address - Country:US
Practice Address - Phone:951-595-9563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-8944103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst