Provider Demographics
NPI:1417020975
Name:DENNIE, TARA MARIE (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:DENNIE
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 GAMBLE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4193
Mailing Address - Country:US
Mailing Address - Phone:501-312-0234
Mailing Address - Fax:
Practice Address - Street 1:1600 RIVERFRONT DRIVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202
Practice Address - Country:US
Practice Address - Phone:501-663-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X334OtherBLUE CROSS BLUE SHIELD