Provider Demographics
NPI:1255685632
Name:BURKETT, TARA L
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:BURKETT
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 1:2425 E SOUTHLAKE BLVD
Mailing Address - Street 2:#100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6674
Mailing Address - Country:US
Mailing Address - Phone:817-442-0222
Mailing Address - Fax:817-442-0223
Practice Address - Street 1:2425 E SOUTHLAKE BLVD
Practice Address - Street 2:#100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6674
Practice Address - Country:US
Practice Address - Phone:817-442-0222
Practice Address - Fax:817-442-0223
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109811174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist