Healthcare Provider Details

I. General information

NPI: 1023576410
Provider Name (Legal Business Name): TARA KAY KLEINSCHMIDT SC 60929123
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 NW FRUIT VALLEY RD STE K
VANCOUVER WA
98660-1275
US

IV. Provider business mailing address

PO BOX 873303
VANCOUVER WA
98687-3303
US

V. Phone/Fax

Practice location:
  • Phone: 803-201-7955
  • Fax: 360-696-4953
Mailing address:
  • Phone: 803-201-7958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: