Provider Demographics
NPI:1376304428
Name:ECKLUND, TARA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:ECKLUND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:WHITMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:843 SCENIC VIEW CT
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7609
Mailing Address - Country:US
Mailing Address - Phone:417-818-6488
Mailing Address - Fax:
Practice Address - Street 1:2673 E SAWYER RD
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-7574
Practice Address - Country:US
Practice Address - Phone:417-324-7646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024299225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant