Provider Demographics
NPI:1841563236
Name:KOESTER, TARA M (DPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:KOESTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:HELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3455 HIGHWAY 81
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9138
Mailing Address - Country:US
Mailing Address - Phone:770-554-0665
Mailing Address - Fax:770-554-0685
Practice Address - Street 1:620 W MACPHAIL RD
Practice Address - Street 2:STE 105
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4474
Practice Address - Country:US
Practice Address - Phone:410-399-9590
Practice Address - Fax:410-399-9591
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist