Provider Demographics
NPI:1619132701
Name:DANA, TARA NOELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:NOELLE
Last Name:DANA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 ROYAL TROON DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-5245
Mailing Address - Country:US
Mailing Address - Phone:303-814-2481
Mailing Address - Fax:
Practice Address - Street 1:12205 GUNSTOCK DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3624
Practice Address - Country:US
Practice Address - Phone:719-481-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04586225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant