Provider Demographics
NPI:1972769123
Name:MITCHEM, TARA MARIE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:MITCHEM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 E MONTCLAIR ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5068
Mailing Address - Country:US
Mailing Address - Phone:417-888-0808
Mailing Address - Fax:417-888-0811
Practice Address - Street 1:929 E MONTCLAIR ST STE 104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5068
Practice Address - Country:US
Practice Address - Phone:417-888-0808
Practice Address - Fax:417-888-0811
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist