Healthcare Provider Details

I. General information

NPI: 1386169399
Provider Name (Legal Business Name): TARA MANELL BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA PETTY

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 N WALTON BLVD STE 1
BENTONVILLE AR
72712-4337
US

IV. Provider business mailing address

7500 SAN FELIPE ST STE 990
HOUSTON TX
77063-1708
US

V. Phone/Fax

Practice location:
  • Phone: 479-802-4798
  • Fax: 479-668-0589
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-37303
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: