Provider Demographics
NPI:1750654604
Name:BRIES, TARA MARIE (MPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:BRIES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:BURMEISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:3385 DEXTER CT
Practice Address - Street 2:SUITE 203
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3494
Practice Address - Country:US
Practice Address - Phone:563-332-9312
Practice Address - Fax:563-332-9316
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist