Provider Demographics
NPI:1306390489
Name:GEIER, TARA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GEIER
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:KETTERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:337 S JOHN ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1619
Mailing Address - Country:US
Mailing Address - Phone:818-564-9417
Mailing Address - Fax:
Practice Address - Street 1:371 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4563
Practice Address - Country:US
Practice Address - Phone:920-979-3726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-07
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI252-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst