Provider Demographics
NPI:1124872072
Name:RAYVONTI, TARA (CPSS BS FPSS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:RAYVONTI
Suffix:
Gender:F
Credentials:CPSS BS FPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 754
Mailing Address - Street 2:
Mailing Address - City:PAUL
Mailing Address - State:ID
Mailing Address - Zip Code:83347-0754
Mailing Address - Country:US
Mailing Address - Phone:208-878-8887
Mailing Address - Fax:208-878-6888
Practice Address - Street 1:PO BOX 754
Practice Address - Street 2:
Practice Address - City:PAUL
Practice Address - State:ID
Practice Address - Zip Code:83347-0754
Practice Address - Country:US
Practice Address - Phone:208-878-8887
Practice Address - Fax:208-878-6888
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty