Provider Demographics
NPI:1508953878
Name:SMITH, TARA E (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:E
Other - Last Name:ROUSONELOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18W431 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4142
Mailing Address - Country:US
Mailing Address - Phone:630-620-1580
Mailing Address - Fax:630-620-1588
Practice Address - Street 1:790 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4909
Practice Address - Country:US
Practice Address - Phone:630-296-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931595OtherMEDICARE RAILROAD
IL202845026Medicare PIN
ILK22770Medicare PIN
ILP00367766Medicare PIN