Provider Demographics
NPI:1902068828
Name:MEYER, TARA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:MEYER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:3534 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1361
Practice Address - Country:US
Practice Address - Phone:260-478-5230
Practice Address - Fax:260-478-5235
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05009664A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100257920OtherGROUP MEDICAID
IN156546OtherGROUP MEDICARE