Provider Demographics
NPI:1972842532
Name:ELLIS, TARA KAY (MS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KAY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-9651
Mailing Address - Country:US
Mailing Address - Phone:405-224-0002
Mailing Address - Fax:405-224-0133
Practice Address - Street 1:1211 S 29TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-9651
Practice Address - Country:US
Practice Address - Phone:405-224-0002
Practice Address - Fax:405-224-0133
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
OK5066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist