Provider Demographics
NPI:1164901294
Name:LODI, TARA MARIE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:LODI
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 1:203 SILVER SADDLE CT
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-0002
Mailing Address - Country:US
Mailing Address - Phone:208-240-3328
Mailing Address - Fax:208-784-1692
Practice Address - Street 1:601 W CAMERON AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2004
Practice Address - Country:US
Practice Address - Phone:208-784-1625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist