Provider Demographics
NPI:1477393569
Name:WASHBURN, TARA NICOLE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:WASHBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:NICOLE
Other - Last Name:RAMSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 PHILLIPS DR
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-7630
Mailing Address - Country:US
Mailing Address - Phone:972-754-5592
Mailing Address - Fax:
Practice Address - Street 1:201 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5638
Practice Address - Country:US
Practice Address - Phone:682-400-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-23-318252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician