Provider Demographics
NPI:1548409931
Name:PEERENBOOM, TARA CHRISTINE (MA, ATC, AT/L)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:CHRISTINE
Last Name:PEERENBOOM
Suffix:
Gender:F
Credentials:MA, ATC, AT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 SAND POINT WAY NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3901
Mailing Address - Country:US
Mailing Address - Phone:425-941-4874
Mailing Address - Fax:
Practice Address - Street 1:3013 S MOUNT BAKER BLVD
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-6139
Practice Address - Country:US
Practice Address - Phone:425-941-4874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1 600370242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer