Provider Demographics
NPI:1164688453
Name:DEAN, TARA LYNNE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNNE
Last Name:DEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 N. ELM ST.
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-4114
Mailing Address - Country:US
Mailing Address - Phone:940-566-5714
Mailing Address - Fax:940-381-0157
Practice Address - Street 1:534 N ELM ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4114
Practice Address - Country:US
Practice Address - Phone:940-566-5714
Practice Address - Fax:940-381-0157
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00935327OtherRAILROAD MEDICARE
TX854T73OtherBC/BS TX - EFFECT 02/01/2011
TXTXB121216Medicare PIN