Provider Demographics
NPI:1871919019
Name:BIRCHALL, TARA BRISSON (LPTA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:BRISSON
Last Name:BIRCHALL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7881
Mailing Address - Country:US
Mailing Address - Phone:910-258-6088
Mailing Address - Fax:
Practice Address - Street 1:300 BLAKE BLVD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8474
Practice Address - Country:US
Practice Address - Phone:910-215-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA1674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant