Provider Demographics
NPI:1568891984
Name:CLUTTER, TARA (AP, LMT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CLUTTER
Suffix:
Gender:F
Credentials:AP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 PORT MALABAR BLVD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5161
Mailing Address - Country:US
Mailing Address - Phone:321-676-3383
Mailing Address - Fax:321-676-3384
Practice Address - Street 1:1071 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 106
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5161
Practice Address - Country:US
Practice Address - Phone:321-676-3383
Practice Address - Fax:321-676-3384
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2949171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist