Provider Demographics
NPI:1205648516
Name:PHILLIPS, TARA MARIE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:DIERINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1615 GATEHOUSE CIR N APT 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-2910
Mailing Address - Country:US
Mailing Address - Phone:719-521-9017
Mailing Address - Fax:
Practice Address - Street 1:1740 CHAPEL HILLS DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5452
Practice Address - Country:US
Practice Address - Phone:719-465-3695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COBACB1267406106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician