Provider Demographics
NPI:1831163716
Name:BUDINGER, TARA JEANINE (PH D)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JEANINE
Last Name:BUDINGER
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 LOMBARDI CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-6798
Mailing Address - Country:US
Mailing Address - Phone:707-547-2220
Mailing Address - Fax:707-547-2229
Practice Address - Street 1:751 LOMBARDI CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-6798
Practice Address - Country:US
Practice Address - Phone:707-547-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14245103T00000X
CO2887103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00228619OtherRR MEDICARE PIN
CO64421376Medicaid
CO64421376Medicaid
COC802324Medicare ID - Type Unspecified