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General NPI Number Information
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NPI Number | 1053877530
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Entity Type | Individual
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Provider Name | TARA HERIDES PTA
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Gender | Female
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Dates
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Enumeration Date | 02/20/2019
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Last Update Date | 02/20/2019
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Provider Practice Location Address
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Address Line | 425 SUMMIT ST
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City | WILD ROSE
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State | WI
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Zip | 54984-6804
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Country | US
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Telephone | 920-622-4342
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Fax | 920-622-3655
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Provider Business Mailing Address
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Address Line | N5436 NUTTER ST
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City | WILD ROSE
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State | WI
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Zip | 54984-6752
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Country | US
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Telephone | 920-642-0147
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2902
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License Number State | WI
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