Provider Demographics
NPI:1407899701
Name:LEWIS, TARA L (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:L
Other - Last Name:MATHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7700 HIGHWAY 65 NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2832
Mailing Address - Country:US
Mailing Address - Phone:763-784-3155
Mailing Address - Fax:763-784-2352
Practice Address - Street 1:11855 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3947
Practice Address - Country:US
Practice Address - Phone:763-767-3140
Practice Address - Fax:763-767-3146
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7739225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5586330Medicaid
MN650001485Medicare PIN