Provider Demographics
NPI:1932877800
Name:SHADLE, TARA MICHELLE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
Last Name:SHADLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MICHELLE
Other - Last Name:SHADLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12410 132ND STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-4663
Mailing Address - Country:US
Mailing Address - Phone:253-224-4525
Mailing Address - Fax:
Practice Address - Street 1:1305 TACOMA AVE S STE 201
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1903
Practice Address - Country:US
Practice Address - Phone:253-396-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator