Provider Demographics
NPI:1528024577
Name:EWALD, TARA LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:EWALD
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 1:2343 ELKHORN STREET
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138
Mailing Address - Country:US
Mailing Address - Phone:720-870-4290
Mailing Address - Fax:
Practice Address - Street 1:15201 E MONCRIEFF PL
Practice Address - Street 2:SUITE G
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-1261
Practice Address - Country:US
Practice Address - Phone:720-374-8522
Practice Address - Fax:720-374-8533
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO472598Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER