Provider Demographics
NPI:1538313630
Name:NELSEN-DEFALCO, TARA
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:NELSEN-DEFALCO
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 1:189 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1339
Mailing Address - Country:US
Mailing Address - Phone:914-420-6896
Mailing Address - Fax:
Practice Address - Street 1:189 PARK AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1339
Practice Address - Country:US
Practice Address - Phone:914-420-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist