Provider Demographics
NPI:1396142287
Name:FRAZER, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FRAZER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:25755 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN
Practice Address - State:MI
Practice Address - Zip Code:48134-1013
Practice Address - Country:US
Practice Address - Phone:734-782-7003
Practice Address - Fax:734-782-7005
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P33780OtherGROUP PTAN
1538198700OtherGROUP NPI
5501017030OtherSTATE LICENSE NUMBER
P33780004OtherIND PTAN