Provider Demographics
NPI:1609285600
Name:ANSPACH, TARA VICTORIA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:VICTORIA
Last Name:ANSPACH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 ROLLING MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MO
Mailing Address - Zip Code:63084-1104
Mailing Address - Country:US
Mailing Address - Phone:717-333-4598
Mailing Address - Fax:
Practice Address - Street 1:110 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-1755
Practice Address - Country:US
Practice Address - Phone:636-583-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014025042235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist