Provider Demographics
NPI:1336425438
Name:AVERILL, TAMRA J (PT)
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:J
Last Name:AVERILL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-1409
Mailing Address - Country:US
Mailing Address - Phone:260-724-2400
Mailing Address - Fax:260-724-2402
Practice Address - Street 1:105 N 13TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1409
Practice Address - Country:US
Practice Address - Phone:260-724-2400
Practice Address - Fax:260-724-2402
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004995A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist