Provider Demographics
NPI:1780422006
Name:PHONGSAVATH, TARAH JUDITH AN (DPT)
Entity type:Individual
Prefix:DR
First Name:TARAH
Middle Name:JUDITH AN
Last Name:PHONGSAVATH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24850 W 191ST ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-9402
Mailing Address - Country:US
Mailing Address - Phone:913-549-6416
Mailing Address - Fax:
Practice Address - Street 1:601 E 63RD ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64110-3303
Practice Address - Country:US
Practice Address - Phone:816-569-2802
Practice Address - Fax:816-569-5436
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-07644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist