Provider Demographics
NPI:1053877530
Name:HERIDES, TARA (PTA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HERIDES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5436 NUTTER ST
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-6752
Mailing Address - Country:US
Mailing Address - Phone:920-642-0147
Mailing Address - Fax:
Practice Address - Street 1:425 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-6804
Practice Address - Country:US
Practice Address - Phone:920-622-4342
Practice Address - Fax:920-622-3655
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2902225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant