Provider Demographics
NPI:1396712949
Name:HENDERSON, TARA B (PT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:B
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:BUCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:61 WHITCHER ST NE
Mailing Address - Street 2:SUITE 1150
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1176
Mailing Address - Country:US
Mailing Address - Phone:678-594-4250
Mailing Address - Fax:770-423-2166
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 1150
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:678-594-4250
Practice Address - Fax:770-423-2166
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0086172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic