Provider Demographics
NPI:1417482605
Name:COLLINS, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:COLLINS
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 1:1618 HEKLA LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1191
Mailing Address - Country:US
Mailing Address - Phone:240-506-5515
Mailing Address - Fax:
Practice Address - Street 1:6100 DAYLONG LN
Practice Address - Street 2:SUITE 203
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1626
Practice Address - Country:US
Practice Address - Phone:410-988-9466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26424225100000X
DCPT871770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist