Healthcare Provider Details

I. General information

NPI: 1912926478
Provider Name (Legal Business Name): TARA ANN BOETTCHER MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA ANN VANRIE MS, CCC-SLP

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 N MAIN ST STE 101-1
MANSFIELD TX
76063-1511
US

IV. Provider business mailing address

PO BOX 174
MANSFIELD TX
76063-0107
US

V. Phone/Fax

Practice location:
  • Phone: 682-400-8132
  • Fax: 682-400-8235
Mailing address:
  • Phone: 682-400-8132
  • Fax: 682-400-8235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number101905
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: