Provider Demographics
NPI:1679678858
Name:POTTER, TARA M (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:POTTER
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 1:546 YATZ DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3286
Mailing Address - Country:US
Mailing Address - Phone:853-341-3424
Mailing Address - Fax:
Practice Address - Street 1:4030 SMITH RD STE 50
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1968
Practice Address - Country:US
Practice Address - Phone:513-631-1988
Practice Address - Fax:513-631-3456
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT011295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214940Medicaid
OH366632Medicare PIN