Provider Demographics
NPI:1912926478
Name:BOETTCHER, TARA ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ANN
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:ANN
Other - Last Name:VANRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-0838
Mailing Address - Country:US
Mailing Address - Phone:817-584-9086
Mailing Address - Fax:817-473-3916
Practice Address - Street 1:1475 HERITAGE PKWY STE 221
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2740
Practice Address - Country:US
Practice Address - Phone:682-400-8132
Practice Address - Fax:682-400-8235
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist