Provider Demographics
NPI:1043761687
Name:WRIGHT, TARA RAY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RAY
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:105 S BLAIR ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4410
Mailing Address - Country:US
Mailing Address - Phone:479-259-2339
Mailing Address - Fax:479-751-4000
Practice Address - Street 1:105 S BLAIR ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4410
Practice Address - Country:US
Practice Address - Phone:479-259-2339
Practice Address - Fax:479-751-4000
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1555SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136914721Medicaid