Provider Demographics
NPI:1831342401
Name:SIMON, TARA L (BA)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:L
Last Name:SIMON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:LOOKADOO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:330 KAY LARKIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177
Mailing Address - Country:US
Mailing Address - Phone:386-329-3780
Mailing Address - Fax:386-385-1269
Practice Address - Street 1:330 KAY LARKIN DRIVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177
Practice Address - Country:US
Practice Address - Phone:386-329-3780
Practice Address - Fax:386-385-1269
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator