Basic Information
| Provider Information | |||||||||
| NPI: | 1073543138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTSON | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 LONDONDERRY RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171095300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176577520 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4310 LONDONDERRY RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171095300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176577520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT016276 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT016276 | 01 | PA | PT | OTHER |