Provider Demographics
NPI:1881192326
Name:BONCK, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BONCK
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 1:1065 LORING DR APT H
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-2563
Mailing Address - Country:US
Mailing Address - Phone:434-941-1736
Mailing Address - Fax:
Practice Address - Street 1:1065 LORING DR APT H
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-2563
Practice Address - Country:US
Practice Address - Phone:434-941-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
22-217714106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management