Provider Demographics
NPI:1053742692
Name:BAILEY, TARA (MS, ATC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 LANCASTER AVE
Mailing Address - Street 2:203 MOBERLY BUILDING
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3100
Mailing Address - Country:US
Mailing Address - Phone:859-248-5265
Mailing Address - Fax:859-622-8857
Practice Address - Street 1:521 LANCASTER AVE
Practice Address - Street 2:203 MOBERLY BUILDING
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3100
Practice Address - Country:US
Practice Address - Phone:859-248-5265
Practice Address - Fax:859-622-8857
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10052255A2300X
MI26010001092255A2300X
OH0035532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer