Provider Demographics
NPI:1326370339
Name:STALLWORTH, TARA (LMT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 FAYETTEVILLE RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6652
Mailing Address - Country:US
Mailing Address - Phone:479-653-0917
Mailing Address - Fax:
Practice Address - Street 1:2308 FAYETTEVILLE RD STE 1100
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-6652
Practice Address - Country:US
Practice Address - Phone:479-653-0917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6378225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist