Provider Demographics
NPI:1710174495
Name:MCCANN, TAMARA (PTA)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MCCANN
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 1:12552 COUNTY ROAD 283 N
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-8067
Mailing Address - Country:US
Mailing Address - Phone:903-983-2138
Mailing Address - Fax:
Practice Address - Street 1:1010 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-2923
Practice Address - Country:US
Practice Address - Phone:903-657-6945
Practice Address - Fax:903-657-9061
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2042679225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant