Provider Demographics
NPI:1306070883
Name:ROBERTS, TARA M (RPT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:466 NINE MILE TREE RD
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078
Mailing Address - Country:US
Mailing Address - Phone:518-883-8733
Mailing Address - Fax:
Practice Address - Street 1:2-8 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095
Practice Address - Country:US
Practice Address - Phone:518-762-8215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022778-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist