Basic Information
| Provider Information | |||||||||
| NPI: | 1578773123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODSON | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 N CHARLOTTE RD | ||||||||
| Address2: | |||||||||
| City: | SULPHUR ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725799789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706120065 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703684377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| 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 | 225200000X | PTA2003 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.