Provider Demographics
NPI:1417198466
Name:STEPHENS, TARA MICHELLE (MS CCC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MICHELLE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MS CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25888 MAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010
Mailing Address - Country:US
Mailing Address - Phone:405-485-3650
Mailing Address - Fax:
Practice Address - Street 1:25888 MAY AVE
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-4811
Practice Address - Country:US
Practice Address - Phone:405-485-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2947235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist