Provider Demographics
NPI:1801122163
Name:MOEN, TARA R (MA SLP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:R
Last Name:MOEN
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1401
Mailing Address - Country:US
Mailing Address - Phone:815-762-4069
Mailing Address - Fax:
Practice Address - Street 1:310 BANBURY RD
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-1260
Practice Address - Country:US
Practice Address - Phone:630-892-7627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.001175235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist