Provider Demographics
NPI:1083740054
Name:ROTH, TARA L (CMT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14365 RIVER CREST DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-8914
Mailing Address - Country:US
Mailing Address - Phone:612-669-0046
Mailing Address - Fax:763-428-8749
Practice Address - Street 1:14365 RIVER CREST DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-8914
Practice Address - Country:US
Practice Address - Phone:612-669-0046
Practice Address - Fax:763-428-8749
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist