Provider Demographics
NPI:1194132373
Name:CENTRA, TARA BROOKE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:BROOKE
Last Name:CENTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BROOKE
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:105 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15851-1244
Mailing Address - Country:US
Mailing Address - Phone:814-653-9514
Mailing Address - Fax:814-653-8842
Practice Address - Street 1:105 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15851-1244
Practice Address - Country:US
Practice Address - Phone:814-653-9514
Practice Address - Fax:814-653-8842
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor