Provider Demographics
NPI:1144793993
Name:DITTER, TARA NICOLE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:NICOLE
Last Name:DITTER
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 1:569 CARTER CT
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-2201
Mailing Address - Country:US
Mailing Address - Phone:920-739-3009
Mailing Address - Fax:920-739-3709
Practice Address - Street 1:569 CARTER CT
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-2201
Practice Address - Country:US
Practice Address - Phone:920-739-3009
Practice Address - Fax:920-739-3709
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician