Provider Demographics
NPI:1033510920
Name:GRANADA, TARA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:GRANADA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 MAJESTIC WAY
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3124
Mailing Address - Country:US
Mailing Address - Phone:407-466-3460
Mailing Address - Fax:
Practice Address - Street 1:488 MAJESTIC WAY
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-3124
Practice Address - Country:US
Practice Address - Phone:407-466-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT25576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist