Healthcare Provider Details

I. General information

NPI: 1306200449
Provider Name (Legal Business Name): TARA VALDEZ L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 W MANSLICK RD
FAIRDALE KY
40118-9581
US

IV. Provider business mailing address

10701 W MANSLICK RD
FAIRDALE KY
40118-9581
US

V. Phone/Fax

Practice location:
  • Phone: 502-367-2112
  • Fax: 502-367-7799
Mailing address:
  • Phone: 502-367-2112
  • Fax: 502-367-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4065
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: