Provider Demographics
NPI:1043563505
Name:PHELPS, TARA STARR (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:STARR
Last Name:PHELPS
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:S
Other - Last Name:BURGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:422 UNION STATION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8965
Mailing Address - Country:US
Mailing Address - Phone:260-450-7630
Mailing Address - Fax:
Practice Address - Street 1:3110 E COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1554
Practice Address - Country:US
Practice Address - Phone:260-408-6732
Practice Address - Fax:317-449-5783
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004392A235Z00000X
OHSP.8958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist