Provider Demographics
NPI:1265814883
Name:CANOVA, TARA (PTA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CANOVA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 SOUTH PRESCOTT STREET
Mailing Address - Street 2:MOMENTUM PHYSICAL REHABILITATION, LLC
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4635
Mailing Address - Country:US
Mailing Address - Phone:901-257-3422
Mailing Address - Fax:901-257-3423
Practice Address - Street 1:80 SOUTH PRESCOTT STREET
Practice Address - Street 2:MOMENTUM PHYSICAL REHABILITATION, LLC
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4635
Practice Address - Country:US
Practice Address - Phone:901-257-3422
Practice Address - Fax:901-257-3423
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNPTA000005668225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446657Medicaid
TN4004523OtherBSBST
TN4004523OtherBSBST