Provider Demographics
NPI:1073809992
Name:KELLY, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KELLY
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 1:805 SE FINCH CIR
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 S 7TH ST STE A
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:IA
Practice Address - Zip Code:50003-1838
Practice Address - Country:US
Practice Address - Phone:515-577-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001385101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health