Provider Demographics
NPI:1366695843
Name:PETERSEN, TARA JEAN (PTA)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:JEAN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 NYE RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9111
Mailing Address - Country:US
Mailing Address - Phone:315-946-5673
Mailing Address - Fax:315-946-5880
Practice Address - Street 1:1529 NYE RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9111
Practice Address - Country:US
Practice Address - Phone:315-946-5673
Practice Address - Fax:315-946-5880
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003290-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant