Provider Demographics
NPI:1841706520
Name:GONZALEZ, TARAH JEANETTE (DPT)
Entity type:Individual
Prefix:
First Name:TARAH
Middle Name:JEANETTE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TARAH
Other - Middle Name:JEANETTE-GONZALEZ
Other - Last Name:SPARKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0070
Mailing Address - Country:US
Mailing Address - Phone:909-337-0844
Mailing Address - Fax:
Practice Address - Street 1:29099 HOSPITAL RD, SUITE 106
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-0070
Practice Address - Country:US
Practice Address - Phone:909-337-0844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist