Provider Demographics
NPI:1881392603
Name:FONTES, TARA RACHELLE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:RACHELLE
Last Name:FONTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RACHELLE
Other - Last Name:DRISCOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:480 S FLOYD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0576
Mailing Address - Country:US
Mailing Address - Phone:208-917-0000
Mailing Address - Fax:
Practice Address - Street 1:480 S FLOYD DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0576
Practice Address - Country:US
Practice Address - Phone:208-917-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst