Provider Demographics
NPI:1861714933
Name:MCMULLEN, TARA RENEE' (DPT)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:RENEE'
Last Name:MCMULLEN
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 1:2010 E RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-2730
Mailing Address - Country:US
Mailing Address - Phone:319-233-3010
Mailing Address - Fax:319-233-3909
Practice Address - Street 1:2010 E RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-2730
Practice Address - Country:US
Practice Address - Phone:319-233-3010
Practice Address - Fax:319-233-3909
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist