Provider Demographics
NPI:1265130298
Name:JOHNSON, TARA ROCHELLE (PTA)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:ROCHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 EMERALD WAY
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-1779
Mailing Address - Country:US
Mailing Address - Phone:937-405-7098
Mailing Address - Fax:
Practice Address - Street 1:2961 WEST SPRING VALLEY PIKE
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-4450
Practice Address - Country:US
Practice Address - Phone:937-802-3108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA013291225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant