Provider Demographics
NPI:1104095694
Name:STEVENSON, TARA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-0933
Mailing Address - Country:US
Mailing Address - Phone:501-581-6045
Mailing Address - Fax:
Practice Address - Street 1:8 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058-9601
Practice Address - Country:US
Practice Address - Phone:501-581-6045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP7988235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164775721Medicaid