Provider Demographics
NPI:1376964866
Name:BIVENS, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BIVENS
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 1:15005 E Q AVE
Mailing Address - Street 2:
Mailing Address - City:CLIMAX
Mailing Address - State:MI
Mailing Address - Zip Code:49034-9764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5659 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1932
Practice Address - Country:US
Practice Address - Phone:269-372-0436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007551225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics