Provider Demographics
NPI:1538481775
Name:HATFIELD, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HATFIELD
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 1:1406 SHEPHERD HILLS RD
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-8563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:504 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:580-371-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100746580E101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0000Medicaid