Provider Demographics
NPI:1144619107
Name:PETERSON, TARA DANIELLE (MS, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DANIELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:896 ASHE LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-8810
Mailing Address - Country:US
Mailing Address - Phone:860-965-3527
Mailing Address - Fax:828-227-7446
Practice Address - Street 1:896 ASHE LOOP RD
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-8810
Practice Address - Country:US
Practice Address - Phone:860-965-3527
Practice Address - Fax:828-227-7446
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-13912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer