Provider Demographics
NPI:1336438811
Name:PETERSON, TARA
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:1470 W HERNDON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0552
Mailing Address - Country:US
Mailing Address - Phone:559-256-2000
Mailing Address - Fax:559-256-2000
Practice Address - Street 1:1470 W HERNDON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-0552
Practice Address - Country:US
Practice Address - Phone:559-256-2000
Practice Address - Fax:559-221-4336
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95943106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist