Provider Demographics
NPI:1639205123
Name:KOHLER, TARA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:KOHLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 CLARK RD
Mailing Address - Street 2:STE 106
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1120
Mailing Address - Country:US
Mailing Address - Phone:734-528-9760
Mailing Address - Fax:734-528-9761
Practice Address - Street 1:3145 CLARK RD
Practice Address - Street 2:STE 102
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1120
Practice Address - Country:US
Practice Address - Phone:734-528-9760
Practice Address - Fax:734-528-9761
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP09920013OtherMEDICARE ID UNSPECIFIED
MI0P09920Medicare PIN