Provider Demographics
NPI:1275934606
Name:QUINN, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:QUINN
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 1:4626 MACKALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4242
Mailing Address - Country:US
Mailing Address - Phone:216-571-0602
Mailing Address - Fax:
Practice Address - Street 1:484 WOODBINE CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44143-1525
Practice Address - Country:US
Practice Address - Phone:216-272-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3133490252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency