Provider Demographics
NPI:1972273449
Name:ROTHE, TARA (MS, LDN, CN, CNS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ROTHE
Suffix:
Gender:F
Credentials:MS, LDN, CN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 WILTON DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-1707
Mailing Address - Country:US
Mailing Address - Phone:630-674-8002
Mailing Address - Fax:
Practice Address - Street 1:3124 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2902
Practice Address - Country:US
Practice Address - Phone:510-434-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5343133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist