Provider Demographics
NPI:1114001765
Name:WILSON, TARA MAHONEY (MSPT, OCS, CSCS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MAHONEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSPT, OCS, CSCS
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2740 SOUTH AVE W STE 101
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-5137
Mailing Address - Country:US
Mailing Address - Phone:406-543-0617
Mailing Address - Fax:406-728-1085
Practice Address - Street 1:2740 SOUTH AVE W STE 101
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-5137
Practice Address - Country:US
Practice Address - Phone:406-543-0617
Practice Address - Fax:406-728-1085
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251X0800X
MTPTP-PT-LIC-1824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic