Provider Demographics
NPI:1568168466
Name:SOSALLA, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SOSALLA
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:N764 COUNTY ROAD FF
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:WI
Mailing Address - Zip Code:53926-9347
Mailing Address - Country:US
Mailing Address - Phone:608-617-6304
Mailing Address - Fax:
Practice Address - Street 1:502 S HIGH ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:WI
Practice Address - Zip Code:53956-1499
Practice Address - Country:US
Practice Address - Phone:920-326-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant