Provider Demographics
NPI:1013143502
Name:GOSSARD, TAMRA LYNN
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:LYNN
Last Name:GOSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMRA
Other - Middle Name:LYNN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:140 UWAPO RD APT 48-105
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7443
Mailing Address - Country:US
Mailing Address - Phone:480-251-4042
Mailing Address - Fax:
Practice Address - Street 1:140 UWAPO RD APT 48-105
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7443
Practice Address - Country:US
Practice Address - Phone:480-251-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health