Healthcare Provider Details

I. General information

NPI: 1861063893
Provider Name (Legal Business Name): TARA MCINTOSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 FOURTH ST
FOSSIL OR
97830-8302
US

IV. Provider business mailing address

PO BOX 207
FOSSIL OR
97830-0207
US

V. Phone/Fax

Practice location:
  • Phone: 541-763-4276
  • Fax:
Mailing address:
  • Phone: 541-763-4276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: