Provider Demographics
NPI:1831669555
Name:CARR, TARA RENEE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:CARR
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RENEE
Other - Last Name:MANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-3032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3611 N ROCHELLE LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1038
Practice Address - Country:US
Practice Address - Phone:618-530-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10879235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist