Provider Demographics
NPI:1164043212
Name:SUTHERLAND, TARA RENEE
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:RENEE
Last Name:SUTHERLAND
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 1:1915 AEROTECH DR STE 180
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-4213
Mailing Address - Country:US
Mailing Address - Phone:719-301-5100
Mailing Address - Fax:
Practice Address - Street 1:1915 AEROTECH DR STE 180
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-4213
Practice Address - Country:US
Practice Address - Phone:719-301-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-116552106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1790211605Medicaid