Provider Demographics
NPI:1669885216
Name:BRENISER, TARA L (LMT, MMP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:BRENISER
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 WAYNE ST STE 6
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9074
Mailing Address - Country:US
Mailing Address - Phone:480-221-7514
Mailing Address - Fax:
Practice Address - Street 1:801 WAYNE ST STE 6
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-9074
Practice Address - Country:US
Practice Address - Phone:480-221-7514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-12663225700000X
INMT21806621225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist