Basic Information
| Provider Information | |||||||||
| NPI: | 1154457562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLASSEN | ||||||||
| FirstName: | TAMMA | ||||||||
| MiddleName: | CAIN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAIN | ||||||||
| OtherFirstName: | TAMMA | ||||||||
| OtherMiddleName: | HUSTON | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3701 NW CARY PARKWAY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 NW CARY PARKWAY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9976 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 068CW | 01 | NC | BCBS OF NC | OTHER | 802636 | 01 | NC | ACN | OTHER |