Provider Demographics
NPI:1821360710
Name:MCDONALD, TARA LYNN
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:MCDONALD
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 1:1721 ROLLETT LN
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-4013
Mailing Address - Country:US
Mailing Address - Phone:812-205-6525
Mailing Address - Fax:
Practice Address - Street 1:1721 ROLLETT LN
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-4013
Practice Address - Country:US
Practice Address - Phone:812-205-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3683235Z00000X
IN22005188A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist