Provider Demographics
NPI:1588965933
Name:PETERSON, TARA MAGEN (RBT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MAGEN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6705 WHITE HORSE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-2503
Mailing Address - Country:US
Mailing Address - Phone:704-654-8599
Mailing Address - Fax:980-938-6088
Practice Address - Street 1:2708 NE 14TH STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist