Provider Demographics
NPI:1265098107
Name:HASTINGS, TARA LYNNETTE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNNETTE
Last Name:HASTINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNNETTE
Other - Last Name:WOODSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MRS
Mailing Address - Street 1:417 COMMERCIAL CT STE C
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-1655
Mailing Address - Country:US
Mailing Address - Phone:941-485-0121
Mailing Address - Fax:
Practice Address - Street 1:417 COMMERCIAL CT
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1655
Practice Address - Country:US
Practice Address - Phone:941-485-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-06549106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician