Provider Demographics
NPI:1215325774
Name:KEMNITZ, TARA ELLAN (LMT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ELLAN
Last Name:KEMNITZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:ELLAN
Other - Last Name:BIVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:11336 E ROSCOE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-4125
Mailing Address - Country:US
Mailing Address - Phone:503-701-1039
Mailing Address - Fax:
Practice Address - Street 1:1467 W ELLIOT RD STE 103
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5167
Practice Address - Country:US
Practice Address - Phone:503-701-1039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#MT-20238225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist