Healthcare Provider Details

I. General information

NPI: 1306187802
Provider Name (Legal Business Name): TARA DEROO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4127 EMBASSY DR SE
GRAND RAPIDS MI
49546-2418
US

IV. Provider business mailing address

4127 EMBASSY DR SE
GRAND RAPIDS MI
49546-2418
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-3200
  • Fax: 616-264-3201
Mailing address:
  • Phone: 616-264-3200
  • Fax: 616-264-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801081584
License Number StateMI

VIII. Authorized Official

Name: MRS. TARA DEROO
Title or Position: SOCIAL WORKER
Credential: LMSW
Phone: 616-264-3200