Provider Demographics
NPI:1477799062
Name:FOSTER, TAMARA LEE (DT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LEE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ASA CREEK CT
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-9353
Mailing Address - Country:US
Mailing Address - Phone:217-254-1956
Mailing Address - Fax:
Practice Address - Street 1:25 ASA CREEK CT
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-9353
Practice Address - Country:US
Practice Address - Phone:217-254-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILTF79291208P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist