Provider Demographics
NPI:1508909375
Name:SAMPLE, TARA S (MHSCCCSLP L)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:S
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MHSCCCSLP L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 JAMES PASS
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3148
Mailing Address - Country:US
Mailing Address - Phone:815-483-8535
Mailing Address - Fax:
Practice Address - Street 1:346 ALANA DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1784
Practice Address - Country:US
Practice Address - Phone:815-462-0514
Practice Address - Fax:815-462-3993
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932126OtherBCBS PROVIDER NUMBER
09138770OtherASHA