Provider Demographics
NPI:1699213827
Name:STEVENS, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:STEVENS
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 1:238 NW A ST
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-2215
Mailing Address - Country:US
Mailing Address - Phone:580-271-2337
Mailing Address - Fax:
Practice Address - Street 1:700 HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8073
Practice Address - Country:US
Practice Address - Phone:580-565-5030
Practice Address - Fax:580-565-5056
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK45-4724630Medicaid