Provider Demographics
NPI:1093124885
Name:LIBSACK, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LIBSACK
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 1:1508 S 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4859
Mailing Address - Country:US
Mailing Address - Phone:509-248-0301
Mailing Address - Fax:509-248-0337
Practice Address - Street 1:1508 S 36TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4859
Practice Address - Country:US
Practice Address - Phone:509-248-0301
Practice Address - Fax:509-248-0337
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60073838225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist