Provider Demographics
NPI:1609161140
Name:ROCHESTER, TARAH BREANNE
Entity Type:Individual
Prefix:
First Name:TARAH
Middle Name:BREANNE
Last Name:ROCHESTER
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 1:8012 SHIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2413
Mailing Address - Country:US
Mailing Address - Phone:219-945-5348
Mailing Address - Fax:
Practice Address - Street 1:8012 SHIN OAK DR
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2413
Practice Address - Country:US
Practice Address - Phone:210-945-5348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106722235Z00000X
TX108032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX676535Medicare PIN
TX207164901Medicaid