Provider Demographics
NPI:1164899571
Name:COLLINS, TARA JOLENE (MS)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:JOLENE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:JOLENE
Other - Last Name:CASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:302 GOLFCREST CIR
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-3502
Mailing Address - Country:US
Mailing Address - Phone:315-415-9520
Mailing Address - Fax:
Practice Address - Street 1:302 GOLFCREST CIR
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-3502
Practice Address - Country:US
Practice Address - Phone:315-415-9520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY706697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist