Provider Demographics
NPI:1447442884
Name:SIMONSON, TARA (DPT)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:HAGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1211
Mailing Address - Street 2:614 SPRUCE ST
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0114
Mailing Address - Country:US
Mailing Address - Phone:541-469-1062
Mailing Address - Fax:541-469-8477
Practice Address - Street 1:614 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-469-1062
Practice Address - Fax:541-469-8477
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR386514Medicare PIN