Provider Demographics
NPI:1306187802
Name:TARA DEROO LLC
Entity Type:Organization
Organization Name:TARA DEROO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-264-3200
Mailing Address - Street 1:4127 EMBASSY DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2418
Mailing Address - Country:US
Mailing Address - Phone:616-264-3200
Mailing Address - Fax:616-264-3201
Practice Address - Street 1:4127 EMBASSY DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2418
Practice Address - Country:US
Practice Address - Phone:616-264-3200
Practice Address - Fax:616-264-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801081584104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty