Provider Demographics
NPI:1225357544
Name:MELTON, TARA ELAINE (LMP)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:ELAINE
Last Name:MELTON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 222ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043
Mailing Address - Country:US
Mailing Address - Phone:425-343-7810
Mailing Address - Fax:
Practice Address - Street 1:6603 220TH SW STE 1C
Practice Address - Street 2:
Practice Address - City:MOUNT LAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043
Practice Address - Country:US
Practice Address - Phone:425-776-1056
Practice Address - Fax:425-776-4357
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60063240225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist