Provider Demographics
NPI:1447597869
Name:STREETER, TARA ROBYN
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ROBYN
Last Name:STREETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2482 LEGION ST
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-4903
Mailing Address - Country:US
Mailing Address - Phone:516-637-5806
Mailing Address - Fax:
Practice Address - Street 1:2482 LEGION ST
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-4903
Practice Address - Country:US
Practice Address - Phone:516-637-5806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY676743121252Y00000X
NY676602121252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNYFRIT2480OtherAMERICAN PROFESSIONALS