Healthcare Provider Details

I. General information

NPI: 1265130298
Provider Name (Legal Business Name): TARA ROCHELLE RIDDELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 WESTERN ROW RD
MASON OH
45040-1438
US

IV. Provider business mailing address

549 CHATHAM PL
TRENTON OH
45067-3100
US

V. Phone/Fax

Practice location:
  • Phone: 937-802-3108
  • Fax:
Mailing address:
  • Phone: 937-405-7098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA013291
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: