Provider Demographics
NPI:1629637418
Name:SCHOPPE, TARA (MED, EDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SCHOPPE
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8104
Mailing Address - Country:US
Mailing Address - Phone:815-478-3310
Mailing Address - Fax:
Practice Address - Street 1:200 2ND ST
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-8104
Practice Address - Country:US
Practice Address - Phone:815-478-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool