Provider Demographics
NPI:1447866447
Name:THOR, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:THOR
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 1:2200 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6308
Mailing Address - Country:US
Mailing Address - Phone:309-797-2900
Mailing Address - Fax:
Practice Address - Street 1:2200 52ND AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6308
Practice Address - Country:US
Practice Address - Phone:309-797-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health