Provider Demographics
NPI:1588621569
Name:VORM, TASHA ALICE (PTA, LAT ATC)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:ALICE
Last Name:VORM
Suffix:
Gender:F
Credentials:PTA, LAT ATC
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:ALICE
Other - Last Name:BOOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT ATC
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-0461
Mailing Address - Country:US
Mailing Address - Phone:515-382-3366
Mailing Address - Fax:515-382-1576
Practice Address - Street 1:630 6TH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:IA
Practice Address - Zip Code:50201
Practice Address - Country:US
Practice Address - Phone:515-382-7008
Practice Address - Fax:515-382-7171
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA754YY89302255A2300X
IA001444225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer