Provider Demographics
NPI:1811159106
Name:WILSON, TARA SANSONE (DPT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:SANSONE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 OLD ALABAMA RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6319
Mailing Address - Country:US
Mailing Address - Phone:561-234-0431
Mailing Address - Fax:
Practice Address - Street 1:11539 PARK WOODS CIR
Practice Address - Street 2:SUITE 502
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4413
Practice Address - Country:US
Practice Address - Phone:678-527-3224
Practice Address - Fax:678-366-5886
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 24102225100000X
GAPT009614208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist