Provider Demographics
NPI:1629670161
Name:DOOLEY, TARITA
Entity Type:Individual
Prefix:MRS
First Name:TARITA
Middle Name:
Last Name:DOOLEY
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 1:905 BALLARD ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2038
Mailing Address - Country:US
Mailing Address - Phone:616-633-5354
Mailing Address - Fax:
Practice Address - Street 1:905 BALLARD ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-2038
Practice Address - Country:US
Practice Address - Phone:616-633-5354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703100135164X00000X
251E00000X, 374U00000X, 385H00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care