Provider Demographics
NPI:1871868513
Name:MIJARES, TARA GENE (MA,BCBA,MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:GENE
Last Name:MIJARES
Suffix:
Gender:F
Credentials:MA,BCBA,MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28245 AVENUE CROCKER
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-0940
Mailing Address - Country:US
Mailing Address - Phone:661-425-4561
Mailing Address - Fax:
Practice Address - Street 1:28245 AVENUE CROCKER STE 220
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1201
Practice Address - Country:US
Practice Address - Phone:661-425-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-10151103K00000X
CA36341235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-12-10151OtherBCBA BOARD CERTIFICATION
CA36341OtherCA STATE SLP LICENSURE