Provider Demographics
NPI:1386607885
Name:ROSE, TARA L (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6107 SOARING DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6120
Mailing Address - Country:US
Mailing Address - Phone:719-659-5856
Mailing Address - Fax:719-219-5691
Practice Address - Street 1:6107 SOARING DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6120
Practice Address - Country:US
Practice Address - Phone:719-659-5856
Practice Address - Fax:719-219-5691
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12026158235Z00000X
CO0289825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO125463Medicaid
12026158OtherASHA CERTIFICATION