Provider Demographics
NPI:1720284060
Name:CAUDLE, TARA (DPT, PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:CAUDLE
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:CAUDLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT, PT
Mailing Address - Street 1:851 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4014
Mailing Address - Country:US
Mailing Address - Phone:701-456-7242
Mailing Address - Fax:
Practice Address - Street 1:851 4TH AVE E
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4014
Practice Address - Country:US
Practice Address - Phone:701-456-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN713425OtherMEDICARE PART B
ND51698Medicaid
NDCOP28486OtherBCBS OF ND