Provider Demographics
NPI:1942607197
Name:BROWN, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12885-0452
Mailing Address - Country:US
Mailing Address - Phone:518-623-3410
Mailing Address - Fax:518-338-0125
Practice Address - Street 1:28 HUDSON ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1204
Practice Address - Country:US
Practice Address - Phone:518-623-3410
Practice Address - Fax:518-338-0125
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist