Provider Demographics
NPI:1578773123
Name:GOODSON, TARA MICHELE (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MICHELE
Last Name:GOODSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 N CHARLOTTE RD
Mailing Address - Street 2:
Mailing Address - City:SULPHUR ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72579-9789
Mailing Address - Country:US
Mailing Address - Phone:870-612-0065
Mailing Address - Fax:
Practice Address - Street 1:1114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556
Practice Address - Country:US
Practice Address - Phone:870-368-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2003225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant