Provider Demographics
NPI:1356468151
Name:HARVEY-GROS, TARA (LOTR)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:HARVEY-GROS
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-5905
Mailing Address - Country:US
Mailing Address - Phone:337-257-2688
Mailing Address - Fax:337-234-1514
Practice Address - Street 1:2413 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-5905
Practice Address - Country:US
Practice Address - Phone:337-257-2688
Practice Address - Fax:337-234-1514
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1068845Medicaid