Provider Demographics
NPI:1598366692
Name:CLARKE, TARAH
Entity Type:Individual
Prefix:
First Name:TARAH
Middle Name:
Last Name:CLARKE
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 1:11223 HOCHSPEIER RD SE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OR
Mailing Address - Zip Code:97352-9805
Mailing Address - Country:US
Mailing Address - Phone:541-671-7696
Mailing Address - Fax:
Practice Address - Street 1:1126 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2933
Practice Address - Country:US
Practice Address - Phone:503-362-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25534225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist