Provider Demographics
NPI:1770807802
Name:COOK, TARA ROSE (LAT, ATC, CEAS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ROSE
Last Name:COOK
Suffix:
Gender:F
Credentials:LAT, ATC, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3607
Mailing Address - Country:US
Mailing Address - Phone:317-902-4441
Mailing Address - Fax:
Practice Address - Street 1:3921 E 75TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3607
Practice Address - Country:US
Practice Address - Phone:317-902-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001466A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer