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General NPI Number Information
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NPI Number | 1669639050
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Entity Type | Individual
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Provider Name | TARA BRINKOETTER
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Gender | Female
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 10/20/2020
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Provider Practice Location Address
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Address Line | 108 W MARKET ST
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3918
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Country | US
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Telephone | 309-827-5351
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Fax | 309-829-6808
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Provider Business Mailing Address
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Address Line | 1698 FORT JESSE RD APT. 4
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City | NORMAL
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State | IL
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Zip | 61761-2219
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Country | US
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Telephone | 217-855-7777
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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