Healthcare Provider Details

I. General information

NPI: 1235681875
Provider Name (Legal Business Name): TARA HEYDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RED HILL DR
PALMERTON PA
18071-1740
US

IV. Provider business mailing address

PO BOX 277
PALMERTON PA
18071-0277
US

V. Phone/Fax

Practice location:
  • Phone: 484-464-3474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number25697600
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: