Provider Demographics
NPI:1215538517
Name:PORTERLIVESAY, TARA RACHELLE (CPM, LM)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RACHELLE
Last Name:PORTERLIVESAY
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:LIVESAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPM, LM
Mailing Address - Street 1:501 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76501-3150
Mailing Address - Country:US
Mailing Address - Phone:347-476-0073
Mailing Address - Fax:
Practice Address - Street 1:501 N 9TH ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76501-3150
Practice Address - Country:US
Practice Address - Phone:347-476-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99422176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty