Provider Demographics
NPI:1972576825
Name:SUNITA, TASHA (PTA)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:SUNITA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:
Other - Last Name:LORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:#104
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-780-0707
Mailing Address - Fax:
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:#104
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-780-0707
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI291-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant