Provider Demographics
NPI:1184830390
Name:GERSTENBERGER, TARA LYNNE
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNNE
Last Name:GERSTENBERGER
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 1:1057 AVONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-3314
Mailing Address - Country:US
Mailing Address - Phone:219-477-1794
Mailing Address - Fax:
Practice Address - Street 1:3405 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-2363
Practice Address - Country:US
Practice Address - Phone:219-462-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001007A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant