Provider Demographics
NPI:1073983052
Name:BURT, TARA ELAINE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ELAINE
Last Name:BURT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7900 AIRWAYS BLVD. BUILDING A
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-536-4096
Mailing Address - Fax:662-536-4099
Practice Address - Street 1:7900 AIRWAYS BLVD. BUILDING A
Practice Address - Street 2:SUITE 2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-536-4096
Practice Address - Fax:662-536-4099
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist