Provider Demographics
NPI:1922421098
Name:MARTIN, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MARTIN
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:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:OK
Mailing Address - Zip Code:74723-0102
Mailing Address - Country:US
Mailing Address - Phone:580-317-5533
Mailing Address - Fax:
Practice Address - Street 1:HC 71 BOX 1A
Practice Address - Street 2:
Practice Address - City:SOPER
Practice Address - State:OK
Practice Address - Zip Code:74759-9721
Practice Address - Country:US
Practice Address - Phone:580-317-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health