Provider Demographics
NPI:1508214891
Name:MAKI, TARA (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MAKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W DOLF ST
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:WI
Mailing Address - Zip Code:54421-9604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 W DOLF ST
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421-9604
Practice Address - Country:US
Practice Address - Phone:715-223-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5417-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist