Provider Demographics
NPI:1114596194
Name:LIDE, TAIESHA SHAKIMA (PTA)
Entity Type:Individual
Prefix:
First Name:TAIESHA
Middle Name:SHAKIMA
Last Name:LIDE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6609 W WOOLBRIGHT RD STE 420
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-0917
Mailing Address - Country:US
Mailing Address - Phone:561-200-4262
Mailing Address - Fax:561-200-4268
Practice Address - Street 1:6609 W WOOLBRIGHT RD STE 420
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-0917
Practice Address - Country:US
Practice Address - Phone:561-200-4262
Practice Address - Fax:561-200-4268
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31003225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant