Provider Demographics
NPI:1124434253
Name:KOLBERG, TARA ROCHELLE (LDM)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ROCHELLE
Last Name:KOLBERG
Suffix:
Gender:F
Credentials:LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8955 N BERKELEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-6017
Mailing Address - Country:US
Mailing Address - Phone:505-249-7592
Mailing Address - Fax:503-233-7686
Practice Address - Street 1:1608 SE ANKENY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1448
Practice Address - Country:US
Practice Address - Phone:503-233-3001
Practice Address - Fax:503-233-7686
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10163507176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife