Healthcare Provider Details

I. General information

NPI: 1255884797
Provider Name (Legal Business Name): TARA COLLEEN OBRIEN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1294 W 6TH ST STE 101
SAN PEDRO CA
90731-2997
US

IV. Provider business mailing address

5621 MANSION CT
LA VERNE CA
91750-1659
US

V. Phone/Fax

Practice location:
  • Phone: 909-706-8898
  • Fax:
Mailing address:
  • Phone: 909-706-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT292886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: