Provider Demographics
NPI:1962845776
Name:YELLIOTT, TARA MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:YELLIOTT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7576 LACIE JAY LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-9520
Mailing Address - Country:US
Mailing Address - Phone:540-336-6017
Mailing Address - Fax:
Practice Address - Street 1:200 NATURES TRL
Practice Address - Street 2:
Practice Address - City:MC DONALD
Practice Address - State:TN
Practice Address - Zip Code:37353-5172
Practice Address - Country:US
Practice Address - Phone:423-339-2517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7740225100000X
GAPT009768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist