Provider Demographics
NPI:1992011696
Name:HOLBROOK, TARA LISEN (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LISEN
Last Name:HOLBROOK
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 1:1 VERNEY DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03047-5000
Mailing Address - Country:US
Mailing Address - Phone:603-547-3311
Mailing Address - Fax:603-547-3232
Practice Address - Street 1:1 VERNEY DR
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:NH
Practice Address - Zip Code:03047-5000
Practice Address - Country:US
Practice Address - Phone:603-547-3311
Practice Address - Fax:603-547-3232
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist