Basic Information
| Provider Information | |||||||||
| NPI: | 1124585435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARF | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | MORGAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERSTON | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | MORGAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 724557 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311391557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578734115 | ||||||||
| FaxNumber: | 7578739619 | ||||||||
| Practice Location | |||||||||
| Address1: | 3135 PEOPLES ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376044130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234541006 | ||||||||
| FaxNumber: | 4233287825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2019 | ||||||||
| LastUpdateDate: | 02/22/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12160 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 12160 | 01 | TN | PT LICENSE | OTHER |