Provider Demographics
NPI:1508001256
Name:ZRALLACK, TARA (SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ZRALLACK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 INDIAN RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-7224
Mailing Address - Country:US
Mailing Address - Phone:772-299-6914
Mailing Address - Fax:772-299-6915
Practice Address - Street 1:4150 INDIAN RIVER BLVD
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32967-7224
Practice Address - Country:US
Practice Address - Phone:772-299-6914
Practice Address - Fax:772-299-6915
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA7080OtherSPEECH LANGUAGE PATHOLOGY LICENSE