Healthcare Provider Details

I. General information

NPI: 1134433618
Provider Name (Legal Business Name): TARA L. SPISAK RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WESTFIELD DR STE 1
ARCHBOLD OH
43502-1005
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 419-445-2015
  • Fax: 419-445-8102
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.4906
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: