Provider Demographics
NPI:1477941086
Name:EINSWEILER-MICKELSON, TARA K
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:K
Last Name:EINSWEILER-MICKELSON
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 1:7289 HICKORY CT
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-9595
Mailing Address - Country:US
Mailing Address - Phone:815-747-2646
Mailing Address - Fax:
Practice Address - Street 1:7289 HICKORY CT
Practice Address - Street 2:
Practice Address - City:EAST DUBUQUE
Practice Address - State:IL
Practice Address - Zip Code:61025-9595
Practice Address - Country:US
Practice Address - Phone:815-747-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist