Provider Demographics
NPI:1922377159
Name:COCKE, TARA LEE (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEE
Last Name:COCKE
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 1:3500 HILLCREST DR.
Mailing Address - Street 2:STE. 1
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3144
Mailing Address - Country:US
Mailing Address - Phone:888-624-6882
Mailing Address - Fax:888-882-4498
Practice Address - Street 1:3500 HILLCREST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3157
Practice Address - Country:US
Practice Address - Phone:888-624-6882
Practice Address - Fax:888-882-4498
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1212341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX292379902Medicaid
TX527779ZH6HMedicare UPIN