Provider Demographics
NPI:1003019761
Name:MOUSER, TARA GRETCHEN (MCDCCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:GRETCHEN
Last Name:MOUSER
Suffix:
Gender:F
Credentials:MCDCCCSLP
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:GRETCHEN
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCDCCCSLP
Mailing Address - Street 1:1321 BUISNESS HWY 60 W
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841
Mailing Address - Country:US
Mailing Address - Phone:573-624-3150
Mailing Address - Fax:
Practice Address - Street 1:505 COURT ST.
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:63825
Practice Address - Country:US
Practice Address - Phone:573-568-4562
Practice Address - Fax:573-568-4563
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist