Provider Demographics
NPI:1952803470
Name:BRUNNER, TARA COLLEEN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:COLLEEN
Last Name:BRUNNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 LONDONBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1309
Mailing Address - Country:US
Mailing Address - Phone:707-494-4266
Mailing Address - Fax:
Practice Address - Street 1:4780 LONDONBERRY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1309
Practice Address - Country:US
Practice Address - Phone:707-494-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11202225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist