Provider Demographics
NPI:1720372881
Name:WEIDE, TARA LYNN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:WEIDE
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 1:1347 MONTERREY BLVD
Mailing Address - Street 2:#182
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-8111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1347 MONTERREY BLVD
Practice Address - Street 2:#182
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-8111
Practice Address - Country:US
Practice Address - Phone:817-312-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator