Provider Demographics
NPI:1467239012
Name:CHILDERS, TARA (LMT)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:CHILDERS
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 1:10225 CLINTON AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-5335
Mailing Address - Country:US
Mailing Address - Phone:612-987-3464
Mailing Address - Fax:
Practice Address - Street 1:7989 SOUTHTOWN CTR STE 110
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1323
Practice Address - Country:US
Practice Address - Phone:612-987-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2201602225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty