Provider Demographics
NPI:1477063964
Name:KISER, TARA LYNN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:KISER
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 1:1315 W RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2207
Mailing Address - Country:US
Mailing Address - Phone:217-621-3773
Mailing Address - Fax:
Practice Address - Street 1:650 N MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:RANTOUL
Practice Address - State:IL
Practice Address - Zip Code:61866-1714
Practice Address - Country:US
Practice Address - Phone:217-892-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist