Healthcare Provider Details

I. General information

NPI: 1639205123
Provider Name (Legal Business Name): TARA LYNN KOHLER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 CLARK RD STE 102
YPSILANTI MI
48197-1120
US

IV. Provider business mailing address

3145 CLARK RD STE 106
YPSILANTI MI
48197-1120
US

V. Phone/Fax

Practice location:
  • Phone: 734-528-9760
  • Fax: 734-528-9761
Mailing address:
  • Phone: 734-528-9760
  • Fax: 734-528-9761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501010523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: