Provider Demographics
NPI:1871701276
Name:CLARK, TARA MARIE (MPT)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 CARRIAGE RUN DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-1679
Mailing Address - Country:US
Mailing Address - Phone:161-421-9325
Mailing Address - Fax:
Practice Address - Street 1:6200 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-8608
Practice Address - Country:US
Practice Address - Phone:161-456-6068
Practice Address - Fax:161-456-6057
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH52682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist