Healthcare Provider Details

I. General information

NPI: 1669639050
Provider Name (Legal Business Name): TARA BRINKOETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W MARKET ST
BLOOMINGTON IL
61701-3918
US

IV. Provider business mailing address

1698 FORT JESSE RD APT. 4
NORMAL IL
61761-2219
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-5351
  • Fax: 309-829-6808
Mailing address:
  • Phone: 217-855-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: